Program Book - Keck School of Medicine of USC - University of ...

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Lower Extremity Dialysis AccessKDOQI Clinical Practice Guidelines:2.1 The order of preference for placement of fistulae in patients with kidneyfailure who choose HD as their initial mode of KRT should be (in descendingorder of preference):2.1.1 Preferred: Fistulae (B)2.1.1.1 A wrist (radiocephalic) primary fistula.2.1.1.2 An elbow (brachiocephalic) primary fistula.2.1.1.3 A transposed brachial basilic vein fistula.2.1.2 Acceptable: AVG of synthetic or biological material, such as:2.1.2.1 A forearm loop graft, preferable to a straight configuration.2.1.2.2 Upper-arm graft.2.1.2.3 Chest wall or “necklace” prosthetic graft or lower-extremityfistula or graft; all upper-arm sites shouldbe exhausted.Lower Extremity Dialysis AccessWho needs lower extremity access?2.1.2.3 Chest wall or “necklace” prosthetic graft or“lower-extremity fistula or graft; all upper-arm sites should beexhausted.”Lower Extremity Dialysis AccessWork up prior to lower extremity access:Review all prior sitesDocument lack of upper extremity access optionsVenogram of upper extremitiesLower extremity pulse examination, ABI's(non-invasive arterial study when any doubt)Venous duplex of lower extremity veinssize, patency, duplicity, prior occult dvt - both legssconsider ascending venogram if prior femoral lines49
Lower Extremity Dialysis AccessWhat are the options for lower extremity access?Analogous to upper extremitiesFistulae -Based on femoral vein or greater saphenous veinAVG -Thigh loops – from common femoral or superficial femoral arteriesLower Extremity Dialysis AccessTechniques: AVFGSV loop first described in 1969Pierre-Paul, et al AVS 2004Lower Extremity Dialysis AccessTechniques: AVFTransposed femoral vein (tFV)Initial description: The Superficial Femoral-Popliteal Vein TranspositionFistula: Description of a New Vascular Access Procedure Jackson, JACS2000Two patientsJackson noted high flows and decreased ABI50
Page 1 and 2: Program Book
Page 3 and 4: Needs AssessmentOver 370,000 patien
Page 5 and 6: ACKNOWLEDGEMENTSWe would like to th
Page 7 and 8: No relevant financial relationships
Page 9 and 10: 2:25 pm Vascular Access Infections,
Page 11 and 12: ESRD in 2012: Socio-economicImpactJ
Page 13 and 14: Geographic variations in adjustedin
Page 15 and 16: Adjusted all-cause & cause specific
Page 17 and 18: ESRD-International ComparisonsPreva
Page 19 and 20: Outcomes for first-time wait-listed
Page 21 and 22: NOTES______________________________
Page 23 and 24: Vascular Access Planning andPreoper
Page 25 and 26: • Veins not circular but ovoid, m
Page 27 and 28: VENOGRAM+ -CFDI+ 17(true positive)-
Page 29 and 30: • Thorough preoperative assessmen
Page 31 and 32: NOTES______________________________
Page 33 and 34: Options and Strategies forUpper Ext
Page 35 and 36: Cimino (radiocephalic) AVFPotential
Page 37 and 38: Two Stage BBAVFStage 1 anastomosis
Page 39 and 40: Brachial Artery-Brachial Vein AVFSu
Page 41 and 42: Forearm AV GraftsLarge surface area
Page 43 and 44: Comparison of brachial-basilic AVfi
Page 45 and 46: Racial differences in AVfistula rat
Page 47 and 48: THANK YOU!46
Page 49: Lower ExtremityDialysis AccessAhmed
Page 53 and 54: Lower Extremity Dialysis AccessData
Page 55 and 56: Lower Extremity Dialysis AccessData
Page 57 and 58: Thank You!LLUMC56
Page 59 and 60: NOTES______________________________
Page 61 and 62: NOTES______________________________
Page 63 and 64: When to Break the Guidelines in Vas
Page 65 and 66: efore initiation of dialysis. It fu
Page 67 and 68: NOTES______________________________
Page 69 and 70: Vascular AccessSurveillanceIs it wo
Page 71 and 72: Monitoring Vs. SurveillanceClinical
Page 73 and 74: Vascular Access Surveillance• Obs
Page 75 and 76: Vascular Access SurveillanceRandomi
Page 77 and 78: Vascular Access SurveillanceRandomi
Page 79 and 80: So why does preemptiveangioplasty n
Page 81 and 82: • ConclusionAccess Surveillance
Page 83 and 84: Management of the Non-MaturingArter
Page 85 and 86: Specific Definition• “…use of
Page 87 and 88: AVF Maturation in Clinical Practice
Page 89 and 90: Hemodialysis Fistula MaturationCons
Page 91 and 92: Physical Exam of AVF• Has an accu
Page 93 and 94: Significant Accessory VeinsSurgical
Page 95 and 96: Venous Stenosis in AVF Body/Outflow
Page 97 and 98: Deep or Excessively Tortuous AVF•
Page 99 and 100: Robert Hye, MD September 27, 2012Ka
Page 101 and 102:
Influence of Access Type onInfectio
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Prevention of HemodialysisAccess In
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Summary of CatheterManagement in CR
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Partial versus Total GraftExcision
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Infected Autogenous DialysisFistula
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Ischemic Steal Syndrome due to Hemo
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Figure 2: (From JACS 2000: Wixon et
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Theoretically the presence of a lar
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Treatment of Ischemic Steal Syndrom
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performing a femoral-femoral bypass
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Ligation may still be an option for
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arterio-venous fistula. Acta Chir S
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David Shavelle, MD September 27, 20
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Definitions• Early (Primary) Fail
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Dual-Sheath TechniqueStep 1: Thromb
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Role of Stent Placement• Stenting
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ComplicationsPulmonary Embolism~10%
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PrePostMedical Therapy• Clopidogr
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Karen Woo, MD September 27, 2012Ass
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Dilation occurs over several years
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Replace with interposition graft◦
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Heparin Proximal and distal control
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Perioperative variableOperative tim
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POLICY ON CULTURAL AND LINGUISTIC C
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KECK SCHOOL OF MEDICINE OF THE UNIV
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