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

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Biologic Reasons for Non-maturation• Failure of arterial dilation– Endothelium of diseased, calcified donor arteries may notbe able to secrete mediators required for flow-mediatedvasodilation• Failure of venous dilation– Endothelium of scarred venous segments injured by priorvenipuncture may not be able to secrete mediators requiredfor flow-mediated vasodilation• Accelerated venous neointimal hyperplasia– Areas of low shear stress within the AVF caused by AVFconfiguration and differences in compliance may lead tofocal areas of neointimal proliferation– Vascular injury caused by vessel stretching, torsion, andskeletonization may result in neointimal hyperplasiaAsif A. Clin J Am Soc Nephrol 2006AVF Maturation in Clinical PracticeAVF Maturation in Clinical Practice• Assessment of literature is very difficult– Definitions of maturation are diverse– Studies are underpowered– Appropriate controls are lacking– Patient population not standardized85
AVF Maturation in Clinical Practice• Assessment of literature is very difficult– Definitions of maturation are diverse– Studies are underpowered– Appropriate controls are lacking– Patient population not standardized• AVF maturation failure rate:– 18 – 53% (Allon M. Kidney Int 2002)– 59.5% (Dember L. JAMA 2008)AVF Maturation in Clinical Practice• Assessment of literature is very difficult– Definitions of maturation are diverse– Studies are underpowered– Appropriate controls are lacking– Patient population not standardized• AVF maturation failure rate:– 18 – 53% (Allon M. Kidney Int 2002)– 59.5% (Dember L. JAMA 2008)• Push to increase the utilization of AVF in the US throughNKF-KDOQI Guidelines and FISTULA FIRST Initiative has ledto increase in maturation failure rates (Patel S. J Vasc Surg 2003;Biuckians A. J Vasc Surg 2008)Factors Associated with AVF Maturation• Clinical factors– AVF location, age, gender, race, diabetes, stroke, dialysisdependence at time of AVF placement• Pathologic factors– Matrix metalloprotease levels, arterial micro-calcification• Pre-operative hemodynamic factors– Vein diameter, artery diameter, routine venous/arterial mapping,venous distensibility, MAP> 90, large-caliber accessory veins• Intra-operative factors– AVF blood flow rates, heparin dose, surgeon experience• Post-operative hemodynamic factors– AVF diameter, AVF flow volume, radial artery resistive index86
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Program Book
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Needs AssessmentOver 370,000 patien
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ACKNOWLEDGEMENTSWe would like to th
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No relevant financial relationships
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2:25 pm Vascular Access Infections,
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ESRD in 2012: Socio-economicImpactJ
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Geographic variations in adjustedin
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Adjusted all-cause & cause specific
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ESRD-International ComparisonsPreva
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Outcomes for first-time wait-listed
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NOTES______________________________
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Vascular Access Planning andPreoper
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• Veins not circular but ovoid, m
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VENOGRAM+ -CFDI+ 17(true positive)-
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• Thorough preoperative assessmen
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NOTES______________________________
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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 and 50: Lower ExtremityDialysis AccessAhmed
Page 51 and 52: Lower Extremity Dialysis AccessWhat
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: Specific Definition• “…use of
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
Page 103 and 104: Prevention of HemodialysisAccess In
Page 105 and 106: Summary of CatheterManagement in CR
Page 107 and 108: Partial versus Total GraftExcision
Page 109 and 110: Infected Autogenous DialysisFistula
Page 111 and 112: Ischemic Steal Syndrome due to Hemo
Page 113 and 114: Figure 2: (From JACS 2000: Wixon et
Page 115 and 116: Theoretically the presence of a lar
Page 117 and 118: Treatment of Ischemic Steal Syndrom
Page 119 and 120: performing a femoral-femoral bypass
Page 121 and 122: Ligation may still be an option for
Page 123 and 124: arterio-venous fistula. Acta Chir S
Page 125 and 126: David Shavelle, MD September 27, 20
Page 127 and 128: Definitions• Early (Primary) Fail
Page 129 and 130: Dual-Sheath TechniqueStep 1: Thromb
Page 131 and 132: Role of Stent Placement• Stenting
Page 133 and 134: ComplicationsPulmonary Embolism~10%
Page 135 and 136: 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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