ARTERIOVENOUS FISTULASTYPES, TRENDS, PHYSICAL

EXAMINATION & TREATMENT

B. Karenko, DOJanuary 25, 2014

• I have no disclosures

Objectives

• Identify types of vascular access• Evaluate trends of vascular access• Physical examination of AV Fistulas– Normal–When to refer

• Treatment

Type of Hemodialysis Access

Synthetic AV Graft Central Venous Catheter

AV Fistula

Radiocephalic Fistula

• Radial Artery to Cephalic Vein

• Forearm• Preferential

Brachiocephalic Fistula

• Brachial Artery to Cephalic Vein

• Antecubital Fossa

Brachiobasilic Fistula

• Brachial Artery to Basilic Vein

• Upper Arm• +/- transposition

AV Fistula

Advantages• Smaller Surgery

• Decreased Infection

• Decreased Thrombosis

• Longer Lifespan– 68% AVF– 49% AVG

Disadvantages• Long Maturation Time

• More Difficult Cannulation

• High Primary Failure with Difficult Vasculature

Allon & Robbin, Kidney Int. 62:1109-1124, 2002.Nassar & Ayus. Kidney Int. 60:1-13, 2001Pisoni RL, et al., Kidney Int. 61:305-306, 2002

Best to Worst

AVF AVG

CVC

Vascular Access Use & Outcomes; An International Perspective from the Dialysis Outcomes & Practice Patterns Study

• Prospective Observational Study

• >300 Hemodialysis Sites

• 12 Countries

• >35,000 patients

Nephrol Dial Transplant. 2008 Oct; 23(10);3219-26.

AV Fistula Use 1996-2007

Nephrol Dial Transplant. 2008 Oct; 23(10);3219-26.

Referral Timeframe

Nephrol Dial Transplant. 2008 Oct; 23(10);3219-26.

Creation to Cannulation

Nephrol Dial Transplant. 2008 Oct; 23(10);3219-26.

Successful Fistula

Adequate Vessels Good Pump

>0.4 cm

Robbins Radiology 225; 59-64, 2002

Monitoring/Surveillance

New AVF• Identify 1° Failures

• Plan for Early Interventions

• Plan for Surgical Revision

Established AVF• Early Detection

– Thrombosis– Inadequate Flow

Physical Examination

• Look

• Listen

• Feel

Look

Radiocephalic

Brachiocephalic

Brachiobasilic (transposed)

Look

Aneurysm & Hematoma

Steal Syndrome

Central Vein Stenosis

• Extremity Swelling

• Collateral Veins

Arm Elevation Test

Auscultation

• Normal Bruit

• High Pitched (stenosis)

Feel (Palpation)

• Inflow Assessment

• Outflow Assessment– Augmentation Test– Absence of Thrill– Pulsitile

Outflow Obstruction

Treatment of Stenosis

• Venous Anastomosis/Outlet

• Significant Lesions–<600 ml/min flow–>50% stenosis on angiogram

Endovascular Angioplasty

• First Line Treatment– 7-8mm peripheral– 12-14mm central

• Poor long term patency

• 50% require repeat treatment within 6-12 months

Am. J Kidney Disease 2001; 37 (5); 1029

Stents

• Three Indications– Angioplasty Failure– Rapid Recurrence of Lesion– Vessel Rupture

J. Am Coll Cardiol Interv. 2010; 3(1); 1-11

Patency

92%80%

30

69%

24%

90

35%

3%

180

Clin J Am Soc Nephrol. 2008, 3(3);699

Surgical Revision of Stenosis

• Advantage– Elimination of the lesion

• Disadvantage– Frequent new lesion development– Loss of venous access sites– Post surgical pain/recovery time

Thrombosis

• Percutaneous/Surgical Thrombectomy

• Thrombolytic Agents

Percutaneous Thrombectomy

J. Am Coll Cardiol Interv. 2010; 3(1); 1-11

Surgical Thrombectomy

J. Am Coll Cardiol Interv. 2010; 3(1); 1-11

Thrombectomy

• Percutaneous/Surgical Thrombectomy

• Primary Patency– 3 months: 30-60%– 6 months: 10-40%

• Elective Angioplasty vs Thrombectomy

J. Vasc. Interv. Radio. 1999; 10 (2pt1):129

Thrombolysis (local)

• Agents

• Contraindications

• Pulse Spray • Mechanical Clot

Disruption

• 50% patent at 1 yr

Major Concern

• Development of Clinically Significant PE

• 650 Thrombectomy Cases– 1 Clinically Significant PE

Kidney Int. 1994; 45(5) 1401

QUESTIONS?