Salman Abdul Baset [email protected] Thesis defense October 29, 2010
GERALD BEATHARD ANNUAL STATE OF THE …€¢Michael Allon • Loay Salman • Ted Saad • Eric...
Transcript of GERALD BEATHARD ANNUAL STATE OF THE …€¢Michael Allon • Loay Salman • Ted Saad • Eric...
Arif Asif M.D.
Professor and Chair
Department of Medicine
Seton Hall-Hackensack Meridian School of Medicine
Jersey Shore University Medical Center, NJ
GERALD BEATHARD ANNUALSTATE OF THE ART LECTURE
Optimizing Dialysis Vascular AccessChallenges & Opportunities
Arteriovenous Fistulas
• Radiocephalic fistula
• Brachiocephalic fistula
• Perforating vein fistula
• Brachiobasilic fistula
• Transpositions
• Lower extremity fistula
Challenges
• Early failure
• Late failure
• Thrombosis
• Hand ischemia
• Aneurysms and pseudoaneurysms
• Infection
• High output failure
Case Presentation
• 52 year old male with ESRD secondary to GNstarted on HD with a tunneled dialysis catheter.
• Left forearm AVF created and could not be usedfor 8 months.
• Suffered from catheter-related sepsis.
Early Fistula Failure
• A fistula that was created successfullyfistula and never developed to supportdialysis or failed within three months ofits use.
Requirement for Fistula Adequacy
• Fistula adequacy requires two variables–Blood flow–Cannulation
Slide from Gerald Beathard
Diameter0.4 cm
Blood Flow500 ml/min
67%
33%
70%
44%
43%
Chance that AVF wasadequate for dialysisYes No
X
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X
X
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Blood Flow500 ml/min
+Diameter 0.4
X 95%
Robbin et al: Radiology 225:59-64, 2002
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2 W 3 W 4 W 6 W 8W 12 W
Time (weeks)
BloodFlow(ml/min)
0
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2 W 3 W 4 W 6 W 8 W 12 W
Diameter(cm)
Time (weeks)
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2 W 3 W 4 W 6 W
BloodFlow(ml/min)
0
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0.25
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0.35
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2 W 3 W 4 W 6 W
Time (weeks)
Diameter(cm)
(B)
(C)(D)
(A)
Time (weeks)
Asif A, Roy-Chaudhury P, Beathard GA: CJASN 1:332-339, 2006
NormalFistulae
EarlyAVFFailure
Causes of Early Fistula Failure
Pre-existing Acquired
Accessory veinArterial stenosisVenous stenosis
Venous stenosisArterial Stenosis
JAS Accessory Veins
RadialArtery
Fistula
Anastomosis
RadialArtery
Anastomosis
Fistula
Accessory vein
Accessory vein
Juxta-anastomoticstenosis
Early Fistula Failure
• 100 cases of early fistula failure
-Juxta-anastomosis stenosis (JAS)
-Accessory vein stenosis
Beathard et al: Kidney International 64:1487-1494, 2003
Inflow Stenosis
• N=223
• AVF: 40%
Most common site was juxta-anastomosis
Asif et al: Kidney International 67:1986-1992, 2005
Radiology 394-398, 1968.
Original paper: Angiography of dialysisaccess was performed by a renal doctor
Juxta-Aanastomotic Stenosis
Juxta-Anastomotic lesionis not new, it has been
there since the creationof an AVF
Role of Physical Examination
• n=68
• Physical examination was performed every 1-2weeks
• 24/68 (35%) had early failure
• All were diagnosed within 8 weeks of accesscreation by physical examination
Asif et al: Kidney International 67:2399-2407, 2005
Basic Principles for Vein Obliteration
• No downstream stenosis
• There is a definite issue related toaccessory vein
-Stealing two much blood (25% the size of AVF)
-Cannulation issues
VNH in the Proximal Vein of an AVF
Courtesy of Prabir Roy-Chaudhury M.D.
Prabir Roy-ChaudhuryRoberto Vazquez-PadronLoay SalmanTimmy LeeJeff Lawsonand others
• Michael Allon
• Loay Salman
• Ted Saad
• Eric Chemla
• Pierre Bourquelot
• Loay Salman
• Don Schon
• Kenneth Abreo
• Thomas Vesely
• Danny Patel
• Tushar Vachharajani
• Anil Agarwal
• Brinda Desiraju
• Dheeraj Rajan
• Suren Shenoy
• Ramesh Soundarajan
• Rick Mishler
• Shouwen Wang
• Charmaine Lok
• Louise Moist
• John Ross
• Larry Spergel
• Rajiv Dhamija
• Ram Dukkipati
• Abigail Falk
• Jack Work