complications and management of av access
TRANSCRIPT
Complications and Management of
AV access
Toufic Safa MD FACS Medical Director - AAA Vascular Care Great Neck NY
Vascular Surgeon St Francis Hospital Roslyn NY
AV Fistula
AV Graft
Types of Hemodialysis
AV Access
47 years after initial description of the AV
fistula it still remains the best access for hemodialysis
38 years after introduction of PTFE graft
material for dialysis access no alternative graft material has been proven to be better
What is the best access for hemodialysis
Michael J Brescia MD James E
Cimino MD Kenneth Appel MD and Baruch J Hurwich MD
NEJM 2751089-1092 1966
Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula
ProcolR
SliderTM
LifeSiteR
VectraR
CryoVeinR
INTERING
HeRo
1- Hematomas
2- Significant Steal
3- Multiple vein branches off of body of fistula
4- Non Maturing AVFrsquos Arterial andor Venous Stenoses
5- Venous Outflow (outside the access zone) Stenosis or Occlusion
6- Aneurysmal degeneration of access vein or graft +-infection
7- Central Venous Stenoses or Occlusions
Complications of
AV ACCESS
HematomasPOST-OP
Hematomas
Massive infiltration post needle access
More common when accessing fistulas for
first time
No time for unnecessary questions or time consuming tests
Immediate
intervention
is necessary before it is too late
SIGNIFICANTAccess Related Steal
SIGNIFICANT STEAL
Can be access andor Limb Threatening
ldquoTimely Intervention is Necessaryrdquo
TechniquesbullOpen Banding or Ligation of access
bullProximalization of arterial anastomosis
bullDRIL Procedure
SIGNIFICANT Access Related Steal
DRIL PROCEDURE
Distal Revascularization amp Interval Ligation
More involved surgical procedure but can be rewarding in the
carefully selected patient
TOO MANY BRANCHES OFF OF THE FISTULA
VEIN
Side Vein Branches can be large and numerous May affect dialysis flow rates if untreated
TechniquesbullPercutaneous Coil Embolization
bullMinimally invasive open ligation
Management of Venous
Side Branches
COOK Tornado coils are most commonly used for that purpose
Easy to handle and deliver
Caution should be exercised not to deliver coil in main fistula vein as that may embolize to the lungs
Still a relatively expensive method of taking care of the problem
Coil Embolization of Fistula Branches
Coil Embolization of Fistula Vein Branch
Pre-Coiling of AVF Branch Successful Coiling of AVF Branch
Minimally Invasive Open LigationPreferred Technique ndash Simple Office Procedure time and cost effective Less risky
Natural History of Primary AV Fistulas is dismal
Only 30 mature into accessible fistulas in one year without intervention
This figure can be pushed up to 60 with secondary interventions (surgical and percutaneous)
Up to 40 of fistulas are deemed non utilizable for access after one year and are abandoned
Non Maturing AV
Fistulas
Biuckians A hellip Glickman MH ldquoThe natural History of autologous fistulashelliprdquo JVS 2008 Feb 47 415-21
Reasons for non maturation of AV Fistula veinbull Vein is small and scarred
bull Vein is deep
bull Vein has multiple branches that siphon blood away
bullArterial inflow stenosisdisease (calcified radial artery)
bull Combination of the above
Current Maturation techniques try to address these problems in order to salvage the ldquonon-salvageablerdquo fistulas
WHY AVFrsquos DO NOT MATURE
Percutaneous Access of Fistula
Balloon Assisted Maturation
Upper arm AVF
Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula Staged angioplasty of vein andor artery performed as necessary
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
AV Fistula
AV Graft
Types of Hemodialysis
AV Access
47 years after initial description of the AV
fistula it still remains the best access for hemodialysis
38 years after introduction of PTFE graft
material for dialysis access no alternative graft material has been proven to be better
What is the best access for hemodialysis
Michael J Brescia MD James E
Cimino MD Kenneth Appel MD and Baruch J Hurwich MD
NEJM 2751089-1092 1966
Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula
ProcolR
SliderTM
LifeSiteR
VectraR
CryoVeinR
INTERING
HeRo
1- Hematomas
2- Significant Steal
3- Multiple vein branches off of body of fistula
4- Non Maturing AVFrsquos Arterial andor Venous Stenoses
5- Venous Outflow (outside the access zone) Stenosis or Occlusion
6- Aneurysmal degeneration of access vein or graft +-infection
7- Central Venous Stenoses or Occlusions
Complications of
AV ACCESS
HematomasPOST-OP
Hematomas
Massive infiltration post needle access
More common when accessing fistulas for
first time
No time for unnecessary questions or time consuming tests
Immediate
intervention
is necessary before it is too late
SIGNIFICANTAccess Related Steal
SIGNIFICANT STEAL
Can be access andor Limb Threatening
ldquoTimely Intervention is Necessaryrdquo
TechniquesbullOpen Banding or Ligation of access
bullProximalization of arterial anastomosis
bullDRIL Procedure
SIGNIFICANT Access Related Steal
DRIL PROCEDURE
Distal Revascularization amp Interval Ligation
More involved surgical procedure but can be rewarding in the
carefully selected patient
TOO MANY BRANCHES OFF OF THE FISTULA
VEIN
Side Vein Branches can be large and numerous May affect dialysis flow rates if untreated
TechniquesbullPercutaneous Coil Embolization
bullMinimally invasive open ligation
Management of Venous
Side Branches
COOK Tornado coils are most commonly used for that purpose
Easy to handle and deliver
Caution should be exercised not to deliver coil in main fistula vein as that may embolize to the lungs
Still a relatively expensive method of taking care of the problem
Coil Embolization of Fistula Branches
Coil Embolization of Fistula Vein Branch
Pre-Coiling of AVF Branch Successful Coiling of AVF Branch
Minimally Invasive Open LigationPreferred Technique ndash Simple Office Procedure time and cost effective Less risky
Natural History of Primary AV Fistulas is dismal
Only 30 mature into accessible fistulas in one year without intervention
This figure can be pushed up to 60 with secondary interventions (surgical and percutaneous)
Up to 40 of fistulas are deemed non utilizable for access after one year and are abandoned
Non Maturing AV
Fistulas
Biuckians A hellip Glickman MH ldquoThe natural History of autologous fistulashelliprdquo JVS 2008 Feb 47 415-21
Reasons for non maturation of AV Fistula veinbull Vein is small and scarred
bull Vein is deep
bull Vein has multiple branches that siphon blood away
bullArterial inflow stenosisdisease (calcified radial artery)
bull Combination of the above
Current Maturation techniques try to address these problems in order to salvage the ldquonon-salvageablerdquo fistulas
WHY AVFrsquos DO NOT MATURE
Percutaneous Access of Fistula
Balloon Assisted Maturation
Upper arm AVF
Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula Staged angioplasty of vein andor artery performed as necessary
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
47 years after initial description of the AV
fistula it still remains the best access for hemodialysis
38 years after introduction of PTFE graft
material for dialysis access no alternative graft material has been proven to be better
What is the best access for hemodialysis
Michael J Brescia MD James E
Cimino MD Kenneth Appel MD and Baruch J Hurwich MD
NEJM 2751089-1092 1966
Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula
ProcolR
SliderTM
LifeSiteR
VectraR
CryoVeinR
INTERING
HeRo
1- Hematomas
2- Significant Steal
3- Multiple vein branches off of body of fistula
4- Non Maturing AVFrsquos Arterial andor Venous Stenoses
5- Venous Outflow (outside the access zone) Stenosis or Occlusion
6- Aneurysmal degeneration of access vein or graft +-infection
7- Central Venous Stenoses or Occlusions
Complications of
AV ACCESS
HematomasPOST-OP
Hematomas
Massive infiltration post needle access
More common when accessing fistulas for
first time
No time for unnecessary questions or time consuming tests
Immediate
intervention
is necessary before it is too late
SIGNIFICANTAccess Related Steal
SIGNIFICANT STEAL
Can be access andor Limb Threatening
ldquoTimely Intervention is Necessaryrdquo
TechniquesbullOpen Banding or Ligation of access
bullProximalization of arterial anastomosis
bullDRIL Procedure
SIGNIFICANT Access Related Steal
DRIL PROCEDURE
Distal Revascularization amp Interval Ligation
More involved surgical procedure but can be rewarding in the
carefully selected patient
TOO MANY BRANCHES OFF OF THE FISTULA
VEIN
Side Vein Branches can be large and numerous May affect dialysis flow rates if untreated
TechniquesbullPercutaneous Coil Embolization
bullMinimally invasive open ligation
Management of Venous
Side Branches
COOK Tornado coils are most commonly used for that purpose
Easy to handle and deliver
Caution should be exercised not to deliver coil in main fistula vein as that may embolize to the lungs
Still a relatively expensive method of taking care of the problem
Coil Embolization of Fistula Branches
Coil Embolization of Fistula Vein Branch
Pre-Coiling of AVF Branch Successful Coiling of AVF Branch
Minimally Invasive Open LigationPreferred Technique ndash Simple Office Procedure time and cost effective Less risky
Natural History of Primary AV Fistulas is dismal
Only 30 mature into accessible fistulas in one year without intervention
This figure can be pushed up to 60 with secondary interventions (surgical and percutaneous)
Up to 40 of fistulas are deemed non utilizable for access after one year and are abandoned
Non Maturing AV
Fistulas
Biuckians A hellip Glickman MH ldquoThe natural History of autologous fistulashelliprdquo JVS 2008 Feb 47 415-21
Reasons for non maturation of AV Fistula veinbull Vein is small and scarred
bull Vein is deep
bull Vein has multiple branches that siphon blood away
bullArterial inflow stenosisdisease (calcified radial artery)
bull Combination of the above
Current Maturation techniques try to address these problems in order to salvage the ldquonon-salvageablerdquo fistulas
WHY AVFrsquos DO NOT MATURE
Percutaneous Access of Fistula
Balloon Assisted Maturation
Upper arm AVF
Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula Staged angioplasty of vein andor artery performed as necessary
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Michael J Brescia MD James E
Cimino MD Kenneth Appel MD and Baruch J Hurwich MD
NEJM 2751089-1092 1966
Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula
ProcolR
SliderTM
LifeSiteR
VectraR
CryoVeinR
INTERING
HeRo
1- Hematomas
2- Significant Steal
3- Multiple vein branches off of body of fistula
4- Non Maturing AVFrsquos Arterial andor Venous Stenoses
5- Venous Outflow (outside the access zone) Stenosis or Occlusion
6- Aneurysmal degeneration of access vein or graft +-infection
7- Central Venous Stenoses or Occlusions
Complications of
AV ACCESS
HematomasPOST-OP
Hematomas
Massive infiltration post needle access
More common when accessing fistulas for
first time
No time for unnecessary questions or time consuming tests
Immediate
intervention
is necessary before it is too late
SIGNIFICANTAccess Related Steal
SIGNIFICANT STEAL
Can be access andor Limb Threatening
ldquoTimely Intervention is Necessaryrdquo
TechniquesbullOpen Banding or Ligation of access
bullProximalization of arterial anastomosis
bullDRIL Procedure
SIGNIFICANT Access Related Steal
DRIL PROCEDURE
Distal Revascularization amp Interval Ligation
More involved surgical procedure but can be rewarding in the
carefully selected patient
TOO MANY BRANCHES OFF OF THE FISTULA
VEIN
Side Vein Branches can be large and numerous May affect dialysis flow rates if untreated
TechniquesbullPercutaneous Coil Embolization
bullMinimally invasive open ligation
Management of Venous
Side Branches
COOK Tornado coils are most commonly used for that purpose
Easy to handle and deliver
Caution should be exercised not to deliver coil in main fistula vein as that may embolize to the lungs
Still a relatively expensive method of taking care of the problem
Coil Embolization of Fistula Branches
Coil Embolization of Fistula Vein Branch
Pre-Coiling of AVF Branch Successful Coiling of AVF Branch
Minimally Invasive Open LigationPreferred Technique ndash Simple Office Procedure time and cost effective Less risky
Natural History of Primary AV Fistulas is dismal
Only 30 mature into accessible fistulas in one year without intervention
This figure can be pushed up to 60 with secondary interventions (surgical and percutaneous)
Up to 40 of fistulas are deemed non utilizable for access after one year and are abandoned
Non Maturing AV
Fistulas
Biuckians A hellip Glickman MH ldquoThe natural History of autologous fistulashelliprdquo JVS 2008 Feb 47 415-21
Reasons for non maturation of AV Fistula veinbull Vein is small and scarred
bull Vein is deep
bull Vein has multiple branches that siphon blood away
bullArterial inflow stenosisdisease (calcified radial artery)
bull Combination of the above
Current Maturation techniques try to address these problems in order to salvage the ldquonon-salvageablerdquo fistulas
WHY AVFrsquos DO NOT MATURE
Percutaneous Access of Fistula
Balloon Assisted Maturation
Upper arm AVF
Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula Staged angioplasty of vein andor artery performed as necessary
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
ProcolR
SliderTM
LifeSiteR
VectraR
CryoVeinR
INTERING
HeRo
1- Hematomas
2- Significant Steal
3- Multiple vein branches off of body of fistula
4- Non Maturing AVFrsquos Arterial andor Venous Stenoses
5- Venous Outflow (outside the access zone) Stenosis or Occlusion
6- Aneurysmal degeneration of access vein or graft +-infection
7- Central Venous Stenoses or Occlusions
Complications of
AV ACCESS
HematomasPOST-OP
Hematomas
Massive infiltration post needle access
More common when accessing fistulas for
first time
No time for unnecessary questions or time consuming tests
Immediate
intervention
is necessary before it is too late
SIGNIFICANTAccess Related Steal
SIGNIFICANT STEAL
Can be access andor Limb Threatening
ldquoTimely Intervention is Necessaryrdquo
TechniquesbullOpen Banding or Ligation of access
bullProximalization of arterial anastomosis
bullDRIL Procedure
SIGNIFICANT Access Related Steal
DRIL PROCEDURE
Distal Revascularization amp Interval Ligation
More involved surgical procedure but can be rewarding in the
carefully selected patient
TOO MANY BRANCHES OFF OF THE FISTULA
VEIN
Side Vein Branches can be large and numerous May affect dialysis flow rates if untreated
TechniquesbullPercutaneous Coil Embolization
bullMinimally invasive open ligation
Management of Venous
Side Branches
COOK Tornado coils are most commonly used for that purpose
Easy to handle and deliver
Caution should be exercised not to deliver coil in main fistula vein as that may embolize to the lungs
Still a relatively expensive method of taking care of the problem
Coil Embolization of Fistula Branches
Coil Embolization of Fistula Vein Branch
Pre-Coiling of AVF Branch Successful Coiling of AVF Branch
Minimally Invasive Open LigationPreferred Technique ndash Simple Office Procedure time and cost effective Less risky
Natural History of Primary AV Fistulas is dismal
Only 30 mature into accessible fistulas in one year without intervention
This figure can be pushed up to 60 with secondary interventions (surgical and percutaneous)
Up to 40 of fistulas are deemed non utilizable for access after one year and are abandoned
Non Maturing AV
Fistulas
Biuckians A hellip Glickman MH ldquoThe natural History of autologous fistulashelliprdquo JVS 2008 Feb 47 415-21
Reasons for non maturation of AV Fistula veinbull Vein is small and scarred
bull Vein is deep
bull Vein has multiple branches that siphon blood away
bullArterial inflow stenosisdisease (calcified radial artery)
bull Combination of the above
Current Maturation techniques try to address these problems in order to salvage the ldquonon-salvageablerdquo fistulas
WHY AVFrsquos DO NOT MATURE
Percutaneous Access of Fistula
Balloon Assisted Maturation
Upper arm AVF
Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula Staged angioplasty of vein andor artery performed as necessary
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
1- Hematomas
2- Significant Steal
3- Multiple vein branches off of body of fistula
4- Non Maturing AVFrsquos Arterial andor Venous Stenoses
5- Venous Outflow (outside the access zone) Stenosis or Occlusion
6- Aneurysmal degeneration of access vein or graft +-infection
7- Central Venous Stenoses or Occlusions
Complications of
AV ACCESS
HematomasPOST-OP
Hematomas
Massive infiltration post needle access
More common when accessing fistulas for
first time
No time for unnecessary questions or time consuming tests
Immediate
intervention
is necessary before it is too late
SIGNIFICANTAccess Related Steal
SIGNIFICANT STEAL
Can be access andor Limb Threatening
ldquoTimely Intervention is Necessaryrdquo
TechniquesbullOpen Banding or Ligation of access
bullProximalization of arterial anastomosis
bullDRIL Procedure
SIGNIFICANT Access Related Steal
DRIL PROCEDURE
Distal Revascularization amp Interval Ligation
More involved surgical procedure but can be rewarding in the
carefully selected patient
TOO MANY BRANCHES OFF OF THE FISTULA
VEIN
Side Vein Branches can be large and numerous May affect dialysis flow rates if untreated
TechniquesbullPercutaneous Coil Embolization
bullMinimally invasive open ligation
Management of Venous
Side Branches
COOK Tornado coils are most commonly used for that purpose
Easy to handle and deliver
Caution should be exercised not to deliver coil in main fistula vein as that may embolize to the lungs
Still a relatively expensive method of taking care of the problem
Coil Embolization of Fistula Branches
Coil Embolization of Fistula Vein Branch
Pre-Coiling of AVF Branch Successful Coiling of AVF Branch
Minimally Invasive Open LigationPreferred Technique ndash Simple Office Procedure time and cost effective Less risky
Natural History of Primary AV Fistulas is dismal
Only 30 mature into accessible fistulas in one year without intervention
This figure can be pushed up to 60 with secondary interventions (surgical and percutaneous)
Up to 40 of fistulas are deemed non utilizable for access after one year and are abandoned
Non Maturing AV
Fistulas
Biuckians A hellip Glickman MH ldquoThe natural History of autologous fistulashelliprdquo JVS 2008 Feb 47 415-21
Reasons for non maturation of AV Fistula veinbull Vein is small and scarred
bull Vein is deep
bull Vein has multiple branches that siphon blood away
bullArterial inflow stenosisdisease (calcified radial artery)
bull Combination of the above
Current Maturation techniques try to address these problems in order to salvage the ldquonon-salvageablerdquo fistulas
WHY AVFrsquos DO NOT MATURE
Percutaneous Access of Fistula
Balloon Assisted Maturation
Upper arm AVF
Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula Staged angioplasty of vein andor artery performed as necessary
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
HematomasPOST-OP
Hematomas
Massive infiltration post needle access
More common when accessing fistulas for
first time
No time for unnecessary questions or time consuming tests
Immediate
intervention
is necessary before it is too late
SIGNIFICANTAccess Related Steal
SIGNIFICANT STEAL
Can be access andor Limb Threatening
ldquoTimely Intervention is Necessaryrdquo
TechniquesbullOpen Banding or Ligation of access
bullProximalization of arterial anastomosis
bullDRIL Procedure
SIGNIFICANT Access Related Steal
DRIL PROCEDURE
Distal Revascularization amp Interval Ligation
More involved surgical procedure but can be rewarding in the
carefully selected patient
TOO MANY BRANCHES OFF OF THE FISTULA
VEIN
Side Vein Branches can be large and numerous May affect dialysis flow rates if untreated
TechniquesbullPercutaneous Coil Embolization
bullMinimally invasive open ligation
Management of Venous
Side Branches
COOK Tornado coils are most commonly used for that purpose
Easy to handle and deliver
Caution should be exercised not to deliver coil in main fistula vein as that may embolize to the lungs
Still a relatively expensive method of taking care of the problem
Coil Embolization of Fistula Branches
Coil Embolization of Fistula Vein Branch
Pre-Coiling of AVF Branch Successful Coiling of AVF Branch
Minimally Invasive Open LigationPreferred Technique ndash Simple Office Procedure time and cost effective Less risky
Natural History of Primary AV Fistulas is dismal
Only 30 mature into accessible fistulas in one year without intervention
This figure can be pushed up to 60 with secondary interventions (surgical and percutaneous)
Up to 40 of fistulas are deemed non utilizable for access after one year and are abandoned
Non Maturing AV
Fistulas
Biuckians A hellip Glickman MH ldquoThe natural History of autologous fistulashelliprdquo JVS 2008 Feb 47 415-21
Reasons for non maturation of AV Fistula veinbull Vein is small and scarred
bull Vein is deep
bull Vein has multiple branches that siphon blood away
bullArterial inflow stenosisdisease (calcified radial artery)
bull Combination of the above
Current Maturation techniques try to address these problems in order to salvage the ldquonon-salvageablerdquo fistulas
WHY AVFrsquos DO NOT MATURE
Percutaneous Access of Fistula
Balloon Assisted Maturation
Upper arm AVF
Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula Staged angioplasty of vein andor artery performed as necessary
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Hematomas
Massive infiltration post needle access
More common when accessing fistulas for
first time
No time for unnecessary questions or time consuming tests
Immediate
intervention
is necessary before it is too late
SIGNIFICANTAccess Related Steal
SIGNIFICANT STEAL
Can be access andor Limb Threatening
ldquoTimely Intervention is Necessaryrdquo
TechniquesbullOpen Banding or Ligation of access
bullProximalization of arterial anastomosis
bullDRIL Procedure
SIGNIFICANT Access Related Steal
DRIL PROCEDURE
Distal Revascularization amp Interval Ligation
More involved surgical procedure but can be rewarding in the
carefully selected patient
TOO MANY BRANCHES OFF OF THE FISTULA
VEIN
Side Vein Branches can be large and numerous May affect dialysis flow rates if untreated
TechniquesbullPercutaneous Coil Embolization
bullMinimally invasive open ligation
Management of Venous
Side Branches
COOK Tornado coils are most commonly used for that purpose
Easy to handle and deliver
Caution should be exercised not to deliver coil in main fistula vein as that may embolize to the lungs
Still a relatively expensive method of taking care of the problem
Coil Embolization of Fistula Branches
Coil Embolization of Fistula Vein Branch
Pre-Coiling of AVF Branch Successful Coiling of AVF Branch
Minimally Invasive Open LigationPreferred Technique ndash Simple Office Procedure time and cost effective Less risky
Natural History of Primary AV Fistulas is dismal
Only 30 mature into accessible fistulas in one year without intervention
This figure can be pushed up to 60 with secondary interventions (surgical and percutaneous)
Up to 40 of fistulas are deemed non utilizable for access after one year and are abandoned
Non Maturing AV
Fistulas
Biuckians A hellip Glickman MH ldquoThe natural History of autologous fistulashelliprdquo JVS 2008 Feb 47 415-21
Reasons for non maturation of AV Fistula veinbull Vein is small and scarred
bull Vein is deep
bull Vein has multiple branches that siphon blood away
bullArterial inflow stenosisdisease (calcified radial artery)
bull Combination of the above
Current Maturation techniques try to address these problems in order to salvage the ldquonon-salvageablerdquo fistulas
WHY AVFrsquos DO NOT MATURE
Percutaneous Access of Fistula
Balloon Assisted Maturation
Upper arm AVF
Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula Staged angioplasty of vein andor artery performed as necessary
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
No time for unnecessary questions or time consuming tests
Immediate
intervention
is necessary before it is too late
SIGNIFICANTAccess Related Steal
SIGNIFICANT STEAL
Can be access andor Limb Threatening
ldquoTimely Intervention is Necessaryrdquo
TechniquesbullOpen Banding or Ligation of access
bullProximalization of arterial anastomosis
bullDRIL Procedure
SIGNIFICANT Access Related Steal
DRIL PROCEDURE
Distal Revascularization amp Interval Ligation
More involved surgical procedure but can be rewarding in the
carefully selected patient
TOO MANY BRANCHES OFF OF THE FISTULA
VEIN
Side Vein Branches can be large and numerous May affect dialysis flow rates if untreated
TechniquesbullPercutaneous Coil Embolization
bullMinimally invasive open ligation
Management of Venous
Side Branches
COOK Tornado coils are most commonly used for that purpose
Easy to handle and deliver
Caution should be exercised not to deliver coil in main fistula vein as that may embolize to the lungs
Still a relatively expensive method of taking care of the problem
Coil Embolization of Fistula Branches
Coil Embolization of Fistula Vein Branch
Pre-Coiling of AVF Branch Successful Coiling of AVF Branch
Minimally Invasive Open LigationPreferred Technique ndash Simple Office Procedure time and cost effective Less risky
Natural History of Primary AV Fistulas is dismal
Only 30 mature into accessible fistulas in one year without intervention
This figure can be pushed up to 60 with secondary interventions (surgical and percutaneous)
Up to 40 of fistulas are deemed non utilizable for access after one year and are abandoned
Non Maturing AV
Fistulas
Biuckians A hellip Glickman MH ldquoThe natural History of autologous fistulashelliprdquo JVS 2008 Feb 47 415-21
Reasons for non maturation of AV Fistula veinbull Vein is small and scarred
bull Vein is deep
bull Vein has multiple branches that siphon blood away
bullArterial inflow stenosisdisease (calcified radial artery)
bull Combination of the above
Current Maturation techniques try to address these problems in order to salvage the ldquonon-salvageablerdquo fistulas
WHY AVFrsquos DO NOT MATURE
Percutaneous Access of Fistula
Balloon Assisted Maturation
Upper arm AVF
Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula Staged angioplasty of vein andor artery performed as necessary
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
SIGNIFICANT STEAL
Can be access andor Limb Threatening
ldquoTimely Intervention is Necessaryrdquo
TechniquesbullOpen Banding or Ligation of access
bullProximalization of arterial anastomosis
bullDRIL Procedure
SIGNIFICANT Access Related Steal
DRIL PROCEDURE
Distal Revascularization amp Interval Ligation
More involved surgical procedure but can be rewarding in the
carefully selected patient
TOO MANY BRANCHES OFF OF THE FISTULA
VEIN
Side Vein Branches can be large and numerous May affect dialysis flow rates if untreated
TechniquesbullPercutaneous Coil Embolization
bullMinimally invasive open ligation
Management of Venous
Side Branches
COOK Tornado coils are most commonly used for that purpose
Easy to handle and deliver
Caution should be exercised not to deliver coil in main fistula vein as that may embolize to the lungs
Still a relatively expensive method of taking care of the problem
Coil Embolization of Fistula Branches
Coil Embolization of Fistula Vein Branch
Pre-Coiling of AVF Branch Successful Coiling of AVF Branch
Minimally Invasive Open LigationPreferred Technique ndash Simple Office Procedure time and cost effective Less risky
Natural History of Primary AV Fistulas is dismal
Only 30 mature into accessible fistulas in one year without intervention
This figure can be pushed up to 60 with secondary interventions (surgical and percutaneous)
Up to 40 of fistulas are deemed non utilizable for access after one year and are abandoned
Non Maturing AV
Fistulas
Biuckians A hellip Glickman MH ldquoThe natural History of autologous fistulashelliprdquo JVS 2008 Feb 47 415-21
Reasons for non maturation of AV Fistula veinbull Vein is small and scarred
bull Vein is deep
bull Vein has multiple branches that siphon blood away
bullArterial inflow stenosisdisease (calcified radial artery)
bull Combination of the above
Current Maturation techniques try to address these problems in order to salvage the ldquonon-salvageablerdquo fistulas
WHY AVFrsquos DO NOT MATURE
Percutaneous Access of Fistula
Balloon Assisted Maturation
Upper arm AVF
Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula Staged angioplasty of vein andor artery performed as necessary
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Can be access andor Limb Threatening
ldquoTimely Intervention is Necessaryrdquo
TechniquesbullOpen Banding or Ligation of access
bullProximalization of arterial anastomosis
bullDRIL Procedure
SIGNIFICANT Access Related Steal
DRIL PROCEDURE
Distal Revascularization amp Interval Ligation
More involved surgical procedure but can be rewarding in the
carefully selected patient
TOO MANY BRANCHES OFF OF THE FISTULA
VEIN
Side Vein Branches can be large and numerous May affect dialysis flow rates if untreated
TechniquesbullPercutaneous Coil Embolization
bullMinimally invasive open ligation
Management of Venous
Side Branches
COOK Tornado coils are most commonly used for that purpose
Easy to handle and deliver
Caution should be exercised not to deliver coil in main fistula vein as that may embolize to the lungs
Still a relatively expensive method of taking care of the problem
Coil Embolization of Fistula Branches
Coil Embolization of Fistula Vein Branch
Pre-Coiling of AVF Branch Successful Coiling of AVF Branch
Minimally Invasive Open LigationPreferred Technique ndash Simple Office Procedure time and cost effective Less risky
Natural History of Primary AV Fistulas is dismal
Only 30 mature into accessible fistulas in one year without intervention
This figure can be pushed up to 60 with secondary interventions (surgical and percutaneous)
Up to 40 of fistulas are deemed non utilizable for access after one year and are abandoned
Non Maturing AV
Fistulas
Biuckians A hellip Glickman MH ldquoThe natural History of autologous fistulashelliprdquo JVS 2008 Feb 47 415-21
Reasons for non maturation of AV Fistula veinbull Vein is small and scarred
bull Vein is deep
bull Vein has multiple branches that siphon blood away
bullArterial inflow stenosisdisease (calcified radial artery)
bull Combination of the above
Current Maturation techniques try to address these problems in order to salvage the ldquonon-salvageablerdquo fistulas
WHY AVFrsquos DO NOT MATURE
Percutaneous Access of Fistula
Balloon Assisted Maturation
Upper arm AVF
Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula Staged angioplasty of vein andor artery performed as necessary
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
DRIL PROCEDURE
Distal Revascularization amp Interval Ligation
More involved surgical procedure but can be rewarding in the
carefully selected patient
TOO MANY BRANCHES OFF OF THE FISTULA
VEIN
Side Vein Branches can be large and numerous May affect dialysis flow rates if untreated
TechniquesbullPercutaneous Coil Embolization
bullMinimally invasive open ligation
Management of Venous
Side Branches
COOK Tornado coils are most commonly used for that purpose
Easy to handle and deliver
Caution should be exercised not to deliver coil in main fistula vein as that may embolize to the lungs
Still a relatively expensive method of taking care of the problem
Coil Embolization of Fistula Branches
Coil Embolization of Fistula Vein Branch
Pre-Coiling of AVF Branch Successful Coiling of AVF Branch
Minimally Invasive Open LigationPreferred Technique ndash Simple Office Procedure time and cost effective Less risky
Natural History of Primary AV Fistulas is dismal
Only 30 mature into accessible fistulas in one year without intervention
This figure can be pushed up to 60 with secondary interventions (surgical and percutaneous)
Up to 40 of fistulas are deemed non utilizable for access after one year and are abandoned
Non Maturing AV
Fistulas
Biuckians A hellip Glickman MH ldquoThe natural History of autologous fistulashelliprdquo JVS 2008 Feb 47 415-21
Reasons for non maturation of AV Fistula veinbull Vein is small and scarred
bull Vein is deep
bull Vein has multiple branches that siphon blood away
bullArterial inflow stenosisdisease (calcified radial artery)
bull Combination of the above
Current Maturation techniques try to address these problems in order to salvage the ldquonon-salvageablerdquo fistulas
WHY AVFrsquos DO NOT MATURE
Percutaneous Access of Fistula
Balloon Assisted Maturation
Upper arm AVF
Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula Staged angioplasty of vein andor artery performed as necessary
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
TOO MANY BRANCHES OFF OF THE FISTULA
VEIN
Side Vein Branches can be large and numerous May affect dialysis flow rates if untreated
TechniquesbullPercutaneous Coil Embolization
bullMinimally invasive open ligation
Management of Venous
Side Branches
COOK Tornado coils are most commonly used for that purpose
Easy to handle and deliver
Caution should be exercised not to deliver coil in main fistula vein as that may embolize to the lungs
Still a relatively expensive method of taking care of the problem
Coil Embolization of Fistula Branches
Coil Embolization of Fistula Vein Branch
Pre-Coiling of AVF Branch Successful Coiling of AVF Branch
Minimally Invasive Open LigationPreferred Technique ndash Simple Office Procedure time and cost effective Less risky
Natural History of Primary AV Fistulas is dismal
Only 30 mature into accessible fistulas in one year without intervention
This figure can be pushed up to 60 with secondary interventions (surgical and percutaneous)
Up to 40 of fistulas are deemed non utilizable for access after one year and are abandoned
Non Maturing AV
Fistulas
Biuckians A hellip Glickman MH ldquoThe natural History of autologous fistulashelliprdquo JVS 2008 Feb 47 415-21
Reasons for non maturation of AV Fistula veinbull Vein is small and scarred
bull Vein is deep
bull Vein has multiple branches that siphon blood away
bullArterial inflow stenosisdisease (calcified radial artery)
bull Combination of the above
Current Maturation techniques try to address these problems in order to salvage the ldquonon-salvageablerdquo fistulas
WHY AVFrsquos DO NOT MATURE
Percutaneous Access of Fistula
Balloon Assisted Maturation
Upper arm AVF
Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula Staged angioplasty of vein andor artery performed as necessary
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Side Vein Branches can be large and numerous May affect dialysis flow rates if untreated
TechniquesbullPercutaneous Coil Embolization
bullMinimally invasive open ligation
Management of Venous
Side Branches
COOK Tornado coils are most commonly used for that purpose
Easy to handle and deliver
Caution should be exercised not to deliver coil in main fistula vein as that may embolize to the lungs
Still a relatively expensive method of taking care of the problem
Coil Embolization of Fistula Branches
Coil Embolization of Fistula Vein Branch
Pre-Coiling of AVF Branch Successful Coiling of AVF Branch
Minimally Invasive Open LigationPreferred Technique ndash Simple Office Procedure time and cost effective Less risky
Natural History of Primary AV Fistulas is dismal
Only 30 mature into accessible fistulas in one year without intervention
This figure can be pushed up to 60 with secondary interventions (surgical and percutaneous)
Up to 40 of fistulas are deemed non utilizable for access after one year and are abandoned
Non Maturing AV
Fistulas
Biuckians A hellip Glickman MH ldquoThe natural History of autologous fistulashelliprdquo JVS 2008 Feb 47 415-21
Reasons for non maturation of AV Fistula veinbull Vein is small and scarred
bull Vein is deep
bull Vein has multiple branches that siphon blood away
bullArterial inflow stenosisdisease (calcified radial artery)
bull Combination of the above
Current Maturation techniques try to address these problems in order to salvage the ldquonon-salvageablerdquo fistulas
WHY AVFrsquos DO NOT MATURE
Percutaneous Access of Fistula
Balloon Assisted Maturation
Upper arm AVF
Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula Staged angioplasty of vein andor artery performed as necessary
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
COOK Tornado coils are most commonly used for that purpose
Easy to handle and deliver
Caution should be exercised not to deliver coil in main fistula vein as that may embolize to the lungs
Still a relatively expensive method of taking care of the problem
Coil Embolization of Fistula Branches
Coil Embolization of Fistula Vein Branch
Pre-Coiling of AVF Branch Successful Coiling of AVF Branch
Minimally Invasive Open LigationPreferred Technique ndash Simple Office Procedure time and cost effective Less risky
Natural History of Primary AV Fistulas is dismal
Only 30 mature into accessible fistulas in one year without intervention
This figure can be pushed up to 60 with secondary interventions (surgical and percutaneous)
Up to 40 of fistulas are deemed non utilizable for access after one year and are abandoned
Non Maturing AV
Fistulas
Biuckians A hellip Glickman MH ldquoThe natural History of autologous fistulashelliprdquo JVS 2008 Feb 47 415-21
Reasons for non maturation of AV Fistula veinbull Vein is small and scarred
bull Vein is deep
bull Vein has multiple branches that siphon blood away
bullArterial inflow stenosisdisease (calcified radial artery)
bull Combination of the above
Current Maturation techniques try to address these problems in order to salvage the ldquonon-salvageablerdquo fistulas
WHY AVFrsquos DO NOT MATURE
Percutaneous Access of Fistula
Balloon Assisted Maturation
Upper arm AVF
Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula Staged angioplasty of vein andor artery performed as necessary
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Coil Embolization of Fistula Vein Branch
Pre-Coiling of AVF Branch Successful Coiling of AVF Branch
Minimally Invasive Open LigationPreferred Technique ndash Simple Office Procedure time and cost effective Less risky
Natural History of Primary AV Fistulas is dismal
Only 30 mature into accessible fistulas in one year without intervention
This figure can be pushed up to 60 with secondary interventions (surgical and percutaneous)
Up to 40 of fistulas are deemed non utilizable for access after one year and are abandoned
Non Maturing AV
Fistulas
Biuckians A hellip Glickman MH ldquoThe natural History of autologous fistulashelliprdquo JVS 2008 Feb 47 415-21
Reasons for non maturation of AV Fistula veinbull Vein is small and scarred
bull Vein is deep
bull Vein has multiple branches that siphon blood away
bullArterial inflow stenosisdisease (calcified radial artery)
bull Combination of the above
Current Maturation techniques try to address these problems in order to salvage the ldquonon-salvageablerdquo fistulas
WHY AVFrsquos DO NOT MATURE
Percutaneous Access of Fistula
Balloon Assisted Maturation
Upper arm AVF
Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula Staged angioplasty of vein andor artery performed as necessary
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Minimally Invasive Open LigationPreferred Technique ndash Simple Office Procedure time and cost effective Less risky
Natural History of Primary AV Fistulas is dismal
Only 30 mature into accessible fistulas in one year without intervention
This figure can be pushed up to 60 with secondary interventions (surgical and percutaneous)
Up to 40 of fistulas are deemed non utilizable for access after one year and are abandoned
Non Maturing AV
Fistulas
Biuckians A hellip Glickman MH ldquoThe natural History of autologous fistulashelliprdquo JVS 2008 Feb 47 415-21
Reasons for non maturation of AV Fistula veinbull Vein is small and scarred
bull Vein is deep
bull Vein has multiple branches that siphon blood away
bullArterial inflow stenosisdisease (calcified radial artery)
bull Combination of the above
Current Maturation techniques try to address these problems in order to salvage the ldquonon-salvageablerdquo fistulas
WHY AVFrsquos DO NOT MATURE
Percutaneous Access of Fistula
Balloon Assisted Maturation
Upper arm AVF
Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula Staged angioplasty of vein andor artery performed as necessary
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Natural History of Primary AV Fistulas is dismal
Only 30 mature into accessible fistulas in one year without intervention
This figure can be pushed up to 60 with secondary interventions (surgical and percutaneous)
Up to 40 of fistulas are deemed non utilizable for access after one year and are abandoned
Non Maturing AV
Fistulas
Biuckians A hellip Glickman MH ldquoThe natural History of autologous fistulashelliprdquo JVS 2008 Feb 47 415-21
Reasons for non maturation of AV Fistula veinbull Vein is small and scarred
bull Vein is deep
bull Vein has multiple branches that siphon blood away
bullArterial inflow stenosisdisease (calcified radial artery)
bull Combination of the above
Current Maturation techniques try to address these problems in order to salvage the ldquonon-salvageablerdquo fistulas
WHY AVFrsquos DO NOT MATURE
Percutaneous Access of Fistula
Balloon Assisted Maturation
Upper arm AVF
Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula Staged angioplasty of vein andor artery performed as necessary
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Reasons for non maturation of AV Fistula veinbull Vein is small and scarred
bull Vein is deep
bull Vein has multiple branches that siphon blood away
bullArterial inflow stenosisdisease (calcified radial artery)
bull Combination of the above
Current Maturation techniques try to address these problems in order to salvage the ldquonon-salvageablerdquo fistulas
WHY AVFrsquos DO NOT MATURE
Percutaneous Access of Fistula
Balloon Assisted Maturation
Upper arm AVF
Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula Staged angioplasty of vein andor artery performed as necessary
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Percutaneous Access of Fistula
Balloon Assisted Maturation
Upper arm AVF
Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula Staged angioplasty of vein andor artery performed as necessary
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Balloon Assisted Maturation
Appropriate Size Balloon is introduced into fistula Staged angioplasty of vein andor artery performed as necessary
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Balloon Assisted Maturation
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Pre and Post BAMinitial stage
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
bull1- Arterial Inflow Lesions
bull2- Venous Access vein Stenoses
bull3- Mixed Arterial and Venous lesions
Arterial Venous or MixedLesions that threaten AV Access
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Multiple arterial inflow stenoses seen in this caseSuccessfully managed with angioplasty
Choice of balloons a bit different than venous angioplasty (smaller diameter flexible and low pressure balloons)
Arterial Inflow Stenosis in a radiocephalic AVF
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Arterial anastomotic lesion is often underdiagnosed and undertreated
Responds very well to balloon angioplasty
Sheath access thru body of AV Graft
Arterial Inflow Stenosis in a Loop Forearm AV Graft
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
AVF Vein Stenoses
Access with Sheath thru vein at elbow and balloon till waste is
obliterated
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Mixed arterial and
venous lesions
A case of arterial anastomotic stenosis and a venous outflow
stenosisBoth lesions were
successfully managed with balloon angioplasty
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
1- Cephalic arch lesions for AV Fistulas
2- Venous anastomosis for AV Grafts
Most common lesion that threatens AV Grafts
Current Techniques of ManagementbullBalloon Angioplasty andor surgical revision
bullStent Graft placement for graft venous anastomotic stenoses and the cephalic arch lesions
Venous outflow Stenoses
(Outside Access Zone)
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Venous outflow stenosis
Stent Graft Placement at the Cephalic Arch
Freedom from re-intervention was improved from 25 to 75 in one year
No Long Term follow-up available
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Venous Outflow Stenosis
AV Graft
Stent Graft Placement at the venous anastomosis of AV Graft
NEJM Volume 362494-503 February 11 2010 Number 6
Stent Graft versus Balloon Angioplasty for Failing Dialysis-
Access GraftsZiv J Haskal MD Scott Trerotola MD Bart Dolmatch MD Earl Schuman MD
Sanford Altman MD Samuel Mietling MD Scott Berman MD Gordon McLennan
MD Clayton Trimmer DO John Ross MD and Thomas Vesely MD
ABSTRACTBackground The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis Balloon angioplasty the
first-line therapy has a tendency to lead to subsequent recoil and restenosis however no other therapies have yet proved to be more effective This study
was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous
anastomotic stenosis in failing hemodialysis grafts
Methods We conducted a prospective multicenter trial randomly assigning 190 patients who were undergoing hemodialysis and who had a venous
anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft Primary end points included
patency of the treatment area and patency of the entire vascular access circuit
Results At 6 months the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group
(51 vs 23 Plt0001) as was the incidence of patency of the access circuit (38 vs 20 P=0008) In addition the incidence of freedom from
subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32 vs 16 P=003 by the
log-rank test and P=004 by the Wilcoxon rank-sum test) The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than
in the stent-graft group (78 vs 28 Plt0001) The incidences of adverse events at 6 months were equivalent in the two treatment groups with the
exception of restenosis which occurred more frequently in the balloon-angioplasty group (Plt0001)
Conclusions In this study percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use
of a stent graft which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty
(ClinicalTrialsgov number NCT00678249 [ClinicalTrialsgov] )
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Venous Outflow Stenosis
AV GraftStent Graft Placement at the venous anastomosis of AV Graft
Personal Experience Improved one and two year patency of AV Graftsto 94 and 82 in a series of 20 patientsAbstract presented at the VASA meeting in Las Vegas May of 2010
Opening Angio Post Angioplasty
Post ViabahnStent Placement
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Aneurysmal Formation
In AV Access
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
True or false aneurysms
Treat venous outflow stenosis first (very common associated finding especially in fistulas)
True aneurysms may be left alone
Treat the ones that are clinically symptomatic pain ulcer high venous pressure on dialysis
Techniquesbull Endovascular Stent Graft Placement for focal and false aneurysms
bull Open resection and replacement with PTFE interposition graft for the large partially thrombosed tortuous dilated and ulcerated aneurysms
ANEURYSMAL FISTULA
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Endovascular Stent Graft Placement Small Focal Pseudoaneurysm with impending rupture in AV Graft body
Off Label use for stent grafts Percutaneous therapy - Instantaneous Exclusion of Aneurysm Graft may be accessed immediately post treatment and thru stent graft if necessary
Upper arm AV Graft with a small PSA treated with a Viabahn Stent Graft
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
STENT GRAFTS Poor Choice for infected AV Access PSA
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Open Resection of AneurysmsReplacement with Interposition PTFE Graft
Fistula Aneurysm with skin ulceration and local infection
One Month Post treatment
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Open Resection of AneurysmsAnother Case of Ulcerated Fistula Aneurysm successfully treated with surgery
On Presentation 6 weeks after treatment
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Present in 8-10 of patients with arm access
Precipitating Factors Prolonged use of tunneled catheters in central veins and presence of pacemakers
Preferred Technique of Management
bullPercutaneous angioplasty and stent placement
Central Venous Stenoses or
Occlusions
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Central Venous
Stenoses or Occlusions
Procedural Tips Use the biggest balloon and stent size on the shelf (like 14mm)
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Central Venous Stenoses or
Occlusions
The biggest technical challenge is traversing the occluded vein segment with wire Sometimes access from 2 sites is necessary (Groin and Arm)One Year Access patency was improved from 22 to 63 in one large series
Endovascular management of central thoracic veno-occlusive diseases in hemodialysis patients a single institutional experience in 69 consecutive patients
Nael K Kee ST Solomon H Katz SG J Vasc Interv Radiol 2009 Jan20(1)46-51 Epub 2008 Nov 20
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
Take Home Message
Create an access for Hemodialysis
1- With minimal complications to the patient
2- Easily Accessible by the dialysis nurses
3- Well accepted by the patient
THANK YOU
THANK YOU