XXVI Corso Nazionale Ante “ DIALISI E TECNOLOGIA”

1616--1717--18 Aprile 2018 Riccione18 Aprile 2018 Riccione

Perchè una buona FAV è vitale?

Matteo Tozzi

Associate Professor-Vascular SurgeryResearch Center for the Study and Application of New Technology in Vascular SurgeryDepartment of Medicine and SurgeryUniversity of InsubriaVarese

Vascular access have

been responsable for

prolonging or saving

the lives of countless the lives of countless

patients

S.E. Wilson. Vascular Access, Wolters Kluwer, 2010

M.J. Brescia J.E. Cimino K. Appel

1966il MODERNO ACCESSO VASCOLARE

Follow-up

Rescue

Programmazione

Tecnicaup

ProgrammazioneProgrammazione

Concept model of simulated progression across vascular access options beginning at

hemodialysis initiation.

David A. Drew et al. JASN 2015;26:183-191

©2015 by American Society of Nephrology

Patient survival by access attempt strategy.

David A. Drew et al. JASN 2015;26:183-191

©2015 by American Society of Nephrology

Total life time in US dollars by access attempt strategy.

David A. Drew et al. JASN 2015;26:183-191

©2015 by American Society of Nephrology

Mean survival (discounted life years) for modeled

patient characteristics

Starting hemodialysis with catheter and mortality risk: persistent association in a

competing risk analysis

Starting hemodialysis with catheter and mortality risk: persistent association in a

competing risk analysis

• Confirming other studies, the use of a CVC at first HD session is one factorindependently associated with the increased risk of adjusted all-cause mortalityduring the first year of HD treatment in Catalonia.

• Why this excess of mortality risk associated with the CVC as the initial VA? Catheter-related bacteremia can explain some cases of death in incident patientsusing a CVC (infection-related mortality). In fact, in Catalonia both UCC and TCC were associated with a significantly higher risk of infection-related death during the first 120 days after HD inception - that is within the highest mortality risk period.

• However, sepsis secondary to CVC cannot fully explain the increase in the mortality rate related to CVC. Confirming previous findings , we havedemonstrated a significantly higher cardiovascular mortality risk associated with demonstrated a significantly higher cardiovascular mortality risk associated with starting HD treatment by CVC during the first year of follow-up. This risk remainssignificantly higher when considering UCC and TCC separately or also both earlyand late periods of mortality. The reason for this increased one-yearcardiovascular mortality risk is unclear. It has been postulated that the use of CVC itself, through the foreign body effect and/or the presence of bacterial biofilmwithout overt CVC infection, may amplify the baseline inflammatory status which, in turn, has been linked with an increased cardiovascular risk . It appears that the elapsing time from CVC insertion until developing a fatal cardiovascular disease islimited and would be against this hypothesis. However, according to the CHOICE study, CVC insertion is associated with a heightened state of inflammation thatpersists even after 60 days from placement .

ProgrammazioneProgrammazione

TCVC : rationaleTCVC : rationale

•• Complications of TCVC:Complications of TCVC:

Infection: 6 x higher cf. AVF Infection: 6 x higher cf. AVF (Bray et al, 2012)(Bray et al, 2012)

Central vein stenosis: prevalence 10Central vein stenosis: prevalence 10--15%15%

A randomized controlled trial and cost-effectiveness analysis of earlycannulation arteriovenous grafts versus tunneled central venous catheters in patients requiring urgent vascular access for hemodialysis.Aitken E1, Thomson P2, Bainbridge L3, Kasthuri R4, Mohr B5, Kingsmore D6.J Vasc Surg. 2017 Mar;65(3):766-774

Central vein stenosis: prevalence 10Central vein stenosis: prevalence 10--15%15%

•• Start with a line, remain on a lineStart with a line, remain on a line

•• Only 44% of AVF created in patients already on dialysis are useable at 6 Only 44% of AVF created in patients already on dialysis are useable at 6 months months (Weber et al, 2009)(Weber et al, 2009)

•• Only 11% of patients starting with TCVC have AVF by 3 months Only 11% of patients starting with TCVC have AVF by 3 months (UK(UK--RR, 2013)RR, 2013)

•• 60% of 60% of crashlanderscrashlanders still have TCVC at 6 months still have TCVC at 6 months (VA Report, 2011)(VA Report, 2011)

Is it possible to avoid TCVC entirely?Is it possible to avoid TCVC entirely?

TCVC : TCVC : razionalerazionale

•• ComplicanzeComplicanze in in TCVC:TCVC:

InfezioneInfezione: 6 x : 6 x nVAnVA (Bray et al, 2012)(Bray et al, 2012)

StenosiStenosi venosevenose centralicentrali: : prevalenzaprevalenza 1010--15%15%

•• Start with a line, remain on a lineStart with a line, remain on a line•• Start with a line, remain on a lineStart with a line, remain on a line

•• solo solo 44% 44% nVAnVA create in create in ptspts in in HdHd e’ e’ utilizzabileutilizzabile a 6 m a 6 m (Weber et al, 2009)(Weber et al, 2009)

•• solo solo 11% 11% deidei pazientipazienti cheche inizianoiniziano con TCVC ha un con TCVC ha un nVAnVA a 3 Ma 3 M((UKUK--RR, RR,

2013)2013)

•• 6060% % incidentiincidenti a 6 M a 6 M dall’iniziodall’inizio hannohanno ancoraancora TCVCTCVC(VA (VA Report, 2011)Report, 2011)

E’ E’ possibilepossibile avereavere un un percorsopercorso interamenteinteramenteCVC free?CVC free?

RisultatiRisultati% % batteriemiabatteriemia in TCVC in TCVC vsvs ecVAGecVAG::

16% (n=10) vs. 3% (n=2) (RR 0.2; P=0.02)16% (n=10) vs. 3% (n=2) (RR 0.2; P=0.02)

MortalitàMortalità in TCVC in TCVC vsvs ecVAGecVAG ::

16% (n=10) vs. 5% (n=3) (RR 0.3; P=0.04)16% (n=10) vs. 5% (n=3) (RR 0.3; P=0.04)

Poorer Poorer QoLQoL in TCVC in TCVC ptspts

> % > % ricoveroricovero accesso accesso correlatocorrelato TCVC TCVC ptspts

ecAVGecAVG :Thrombosis 27%; steal 8%; local infection 2%; wound problems 2%; :Thrombosis 27%; steal 8%; local infection 2%; wound problems 2%; pseudoaneurysmpseudoaneurysm 2%2%

NessunaNessuna differenzadifferenza di di costocosto (£11,393 vs. £ 9,692; P=0.24)(£11,393 vs. £ 9,692; P=0.24)

ecVAGUrgentUrgent

pts

48 pts 2016-2017: ec time 1,35h-12h > 4 (8,3%) haematoma / 2 (4,1%)

NO tCVC / 15 (31%) nVA

Pts HD

VA/CVC N°75 ESRD N°25

N°2 Cannulation

> 4 d

Early cannulation

23h(range12-30h)

N°73 E.Cannulation < 4

d

N°19 Urgent HD

Immediate cannulation

No native option

N°6 > 4 d

Tot: 1485 dys & removed 45 CVC & spared 55 TCVCM. Tozzi et al: VASA 2016

ecVAGBridgeBridge

ToNative

Graft bridge to native

Early cannulation prosthetic graft (Acuseal) for arteriovenous access: a useful option to provide a personal vascular access solution.Aitken EL, Jackson AJ, Kingsmore DB.J Vasc Access. 2014 Nov-Dec;15(6):481-5.

22 pts 2015-2016:

15 pts > 98 days explanted >

nVAnVA

7pts wathing list for expalntation

No failure aVA

4 thrombosis pVA

TecnicaTecnica

AVG brachio-Basilic – Loopafter radial artery Harvesting for CABG

Newdevicesdevices

VASqVASq

Radial artery deviation and reimplantationinhibits venous juxta-anastomotic stenosis and increases primary patency of radial-cephalicfistulas for hemodialysisNirvana Sadaghianloo, MD,a,b Serge Declemy, MD,a,b Elixène Jean-Baptiste, MD, PhD,a,bPierre Haudebourg, MD,a,b Christophe Robino, MD,c Mohamed Shariful Islam, MD,b,dRéda Hassen-Khodja, MD,a,b

pVAVena Vena

inadeguata

Crown anasthomosis T-T

Crown anasthomosis T-T

VectorVector FlowFlow

Anastomosi VenosaVenosasuturless

Clinical case

F. P. female 64 y

3 MM

Follow-upFollow-up

Pervietà primaria media non assistita è stimata tra 10 – 40% ad un anno indipenedentemente dal tipo(Joffe et al.)(Joffe et al.)

NECESSARIA SORVEGLIANZA

TROMBOSITROMBOSI

Più frequente causa di perdita dell’accesso vascolarePiù frequente causa di perdita dell’accesso vascolare

Stenosi emodinamicamente significative

Bassa gittata, ipotensione, incremento Ht, disordini della coagulazione

CAUSA

ASSOCIATO A

Turbolenze, shear stress, ripetute canulazioni

Imparato AM et al. Intimal and neointimal fibrous proliferation causing failureof arterial reconstruction Surgery, 1972;72(6):1007-1017

stenosi ≥ 50% del lume

NKF-KDOQI, Clinical Practice Guidelines, 2008SVS, clinical practice guidelines, 2012

Più frequente sul versante venoso

14%

28%

STENOSISTENOSI

58%

14%

Kanterman RY et al. Dialysis access graft: anatomic location od venous stenosis and resultsof angioplasty. Radiology, 1995;195(1):135-9

PERCHE’

NECESSARIONECESSARIO

SORVEGLIANZA?

Razionale

Frequenti

ricognizioni

Precoce

identificazione

Precoce

trattamento

E’ davvero ovvio?

• Quale metodica..

• Quanto frequenti…• Quanto frequenti…

• Precoce trattamento

> sopravvivenza?

Come?

National Kidney Foundation (NKF) Kidney Disease

Outcome Quality Initiative (KDOQI) Clinical Practice

Guidelines 2006

surveillance strongly depends on narrow clinical

monitoring performed by skilled personnel with 70% monitoring performed by skilled personnel with 70%

positive predictive value and 90% specificity

Valutazione clinica

EcocolorDoppler

Dati emodinamici

Valutazione clinica

Clinical access assessmentJ Vasc Access 2014; 15(Suppl. 7): 20 – 27

Nicola Tessitore, Valeria Bedogna, Giuseppe Verlato, Albino Poli

Vascular access creation and care should

be provided by nephrologistsJ Vasc Access 2015; 16(Suppl. 9): 20 - 23

Marko Malovrh

Ecocolor-Doppler

Routine VA surveillance and monitoring is recommended. Nephrologists should

be trained to recognize VA problems and to pay attention on the quality of HD

treatment based on clinical signs and laboratory tests, on progressive increase

of venous inflow pressure, postpuncture bleeding and decrease or critical

reduction of arterial blood flow during HD treatment. Each AVF/graft should

be evaluated by physical examination before cannulation at each HD treatment

and on a regular basis on all HD patients. The primary purpose of this

examination is to detect vascular stenosis or other abnormalities that

might lead to AVF dysfunction. Surveillance by physical examination is easily

learned, easily performed, quickly done and economical

Ecocolor-Doppler

How to prolong the patency of vascular access.Glazer S, Saint L, Shenoy S. Contrib Nephrol. 2015;184:143-52

Prolonging the patency and limiting the complications of a functioning

hemodialysis (HD) access require a multidisciplinary approach. It begins

with careful access planning that is executed and continually reinforced bywith careful access planning that is executed and continually reinforced by

physicians and facility staff encouraging active patient participation. Vascular

access (VA) dysfunctions identified by regular monitoring and surveillance

need further evaluation. Color duplex ultrasound is evolving as the

primary tool to evaluate functional implication of the structural problems

in the VA. While ease of scheduling makes endovascular management

attractive, definitive surgical management provides better longevity and

should be used when indicated. Timing of intervention and selection of

technique depend on optimal use of available expertise and the nature of the

problem. Avoiding a bridging HD catheter should be a priority while prolonging

access patency and improving patient safety.

Eco color Doppler

Impact of Duplex Ultrasound Surveillance Program on

Patency of Prosthetic Arteriovenous Graft for

Hemodialysis : A Single Center Experience.

Raffaella M, Rodolfo P, Gianluca F, Gabriele D, Grazia FM, Rosalinda

D,

Antonio F, Mauro G, Stella AAntonio F, Mauro G, Stella AAnn Vasc Surg. 2015 May 22. pii: S0890-5096

The DUS surveillance allows a greater secondary patency

compared with a clinical evaluation and reduce CVC

placement rate.

SurgicalTechnique

TrombectomyAnastomotic revisionIntimal Hy. Removaldeclotting

Endovascolarapproch

Plain BaloonHigh pressureCutting BaloonCutting BaloonBMSCovered stent

non abbiate paura dellaperfezione tanto non la potretemai raggiungereSalvador Dalì