Vascular Access creation in the US A surgical perspectivec.ymcdn.com/sites/€¦ · Vascular Access...
Transcript of Vascular Access creation in the US A surgical perspectivec.ymcdn.com/sites/€¦ · Vascular Access...
Vascular Access creation in the USA surgical perspective
Surendra Shenoy M.D., Ph.D.
Section of TransplantationDepartment of Surgery
DisclosuresNo specific disclosures pertaining to
the topic of presentation
50thAnniverseryofInternal (access) shunts
Brescia MJ, Cimino JE, Appel K , Hrwich BJ NEJY;1966:1089
Cimino Appel Brescia
Cimino Appel Brescia
Brescia Cimino AppelXXXXXXXXX
Vascular Access in USSurgical perspective….. Background
Vascular Access in USSurgical perspective
Health care changes in US: Impact on VA
Social Security Amendments – 1972All persons with ESRD eligible for medicare
Assured reimbursement
Improved access to healthcare
Physician’s Behavioral change
USRDS ADR Ch XII 1994
Patient profile: elderly, diabetics, ↑ co morbidities
Increased experience better care and longevity
Beneficiaries 10,000 (1970) to >150,000 (1990)
Background
Background
• Fistulae better than shunts• Need for anatomic suitability• Maturation period• Uncertainty of success
Vascular Access in USSurgical perspective….
Problems with vascular access
AVGBiologic
Xenografts Allograft
Cross linkedCross link
Synthetic
1978 - Human Umbilical vein(Biograft ®, Meadox Meds)- Saphenous vein
1972- Bovine carotid artery(Artegraft ®, Artegraft Inc)
Non cross linkednon antigenic Cryopreserved
(1985) antigenic
Non cross linked
1976
- ePTFE
AVFMultitudes of sites with very little technical changes Snuff box,high & low wrist fistula, brachiocephalic, Gracz AVF, basilicatransposition UA, basilic transposition FA
No attention paid to cause of failure – no need due to short longevity
Background
Goodkin DA et.al. JASN 2003; 14: 3270
NKF-KDOQI (1995)
‘Fistula First’ (2003)
Vascular Access in USSurgical perspective….
Access population differences Access modality differences Outcome differences
US ESRD population (200,000) ~ 80% AVGJapan ESRD (175,00) ~ 85% AVFEuropean ESRD (30,000) ~ 80% AVF
Schena FP Kidney Int 2000; 57: S39-45
Increaseddialysis dose
Decreased BP Phos control
Decreased LVH Better nutritionImproved QOL
Williams AW. AJKD 2004;43:90 Kliger AS. CJASN 2009;4:S121
Quality of dialysis depends onfunctioning of vascular access
RAS inhibitors, statins, BP control, Phos control, fluid control etc.
AVG, Catheters and AVF
Strategies to improve ESRD mortality(2000-present)
Vascular access practice patternsAccess performed by well-trained surgeonsSurgeons trained in graft eraMinimal experience in AVFAccess = joining a vein/graft to arteryHigh rates of primary failure TDC prevalence
Dember LM et.al. JAMA 2008;299:2164-71
Origin and proliferation of image guidedprocedures and devices and catheter industry
Lacson E, et.al. AJKD 2007; 50:379-95
Adaptation of medical communityto changing practice pattern
Individual dataAVF 79%
AVG 21%
Functional AVF maturation 81.7%
Committed to catheter 3.5%
AVF maturation (ITT) 72%
1 yr. Primary patency 42.5%
1 yr. Secondary patency 81.8 %
Median (range 1.2 - 97.7 mon) followup 36.1 mon
AVF procedures per functional year 0.68
Patient outcome >85% AVF
VA creation: Changing outcome
Richardson AI et.al. JVA 2009; 10: 199-02 Dember LM et.al. JAMA 2008;299:2164-71Jennings WC. Arc Surg 2006; 141:27-32 Lucas J. J Vasc Surg 2016;
VA surgical practice patternsLarge Academic Medical center
~ 300 cases in 1 year by 8 surgeons 2 Surgeons performed >60% of procedures These surgeons performed >80% AVF One recent trainee also performed >80% AVF Other surgeons performed AVF ~ 50% patients
Patterns reflect a changing practicepatterns showing improvement in training
and importance of access championsVachharajani N,et.al. J Vasc Surg 2015: s1-s4
17%
65%
20%
AVF
Catheter
80%
USRDS 2015
VA patterns in incident patientsCMS 2728 & crown web data 2013
Vascular access surgical training
Eidt JF. JVS 2011; 53: 1130-40
Vascular Board certification data300% increase in AVF (5 in 2003 to 18)
VA is considered a resident case19 residents graduated between 2012 -2014
Required vascular cases 44Average AVF/AVG(range 11-73) 33Revisions (range 1-27) 11Trainees interested in VA 62
Current surgical trainingprovides ample opportunity
Vachharajani N,et.al. J Vasc Surg 2015: s1-s4
What are some issues?Difficulty to make AVA attractive
High rates of failure
Lack of scientific understanding
Lack of innovative research
Multidisciplinary nature of the practice
Fragmentation of careLack of advocacy
Inflow
Central outflow
PeripheralOutflow
NAS(Needle access
Segment)
Stenosis is the cause for majority of access circuit failure
Capacity of the pumpdiameter, stiffness & length
of the tubesdetermines the flow
Physiology: AVA maturation & failure
AVG is NAS of the circuit
Where we are now?
Growing patient population will propelchanges in the field
USRDS 2015
~ 117,000 patients started dialysis in 2012
Total ESRD population ~661,648Hemodialysis (91%) ~421,000Peritoneal Dialysis (9%) ~ 45,000Post transplant ~ 193,000
SummarySurgical problems associated with
vascular access were part of the evolutionof the speciality.
The current eduction system is robustenough to adjust the need of the changing
practice patterns.There is a need for better understandingand research in the field to improve the
current outcomeIncreasing prevalence of ESRD will
continue to fuel the progress andinnovation
Vascular Access creation in the USA surgical perspective