Protesi artero-venose:

indicazioni e materiali.

Massimo Morosetti

Direttore UOC Nefrologia e Dialisi

Direttore DEA

Ospedale GB Grassi Roma

FAV protesiche prossimali

FAV protesiche arto inferiore.

La protesi ideale

Emocompatibile

Biocompatibile Duratura

Maneggevole

Elastica

Flessibile

Buona compliance

Resistente alle infezioni

Resistente alle punture

No seroma

No trombogenesi

?

Carboflo

Carboflo

Risultati

Venaflo II

Venaflo II

Flusso nell’anastomosi venosa

Risultati

AVflo© Vascular Access Graft

Multistrato

A novel electrospun nano-fabric graft allows early cannulation

access and reduces exposure to central venous catheters.

Karatepe C, Aitinay L, Yetim TD, Dagli C, Dursun S

Results: Successful access was achieved in all 24 patients within 48 hours.

In 50% of the patients cannulation was performed within 24 hours without

increasing the complication rate. Twelve month primary and secondary

patencies were 50% and 70.8%, respectively. Excluding early failures

(within 30 days) because of surgical problems, 12 month primary and

secondary patencies were 75% and 81.2% respectively. Complication and

infection rates were 10.94 and 0.49/1000 dialysis procedures, respectively.

No pseudoaneurysms or seromas were documented at 18 months.

Conclusions: Early cannulation was successful in all patients with good 12-

month primary and secondary patency rates, compared to data reported by

others on polytetrafluoroethylene (PTFE) grafts. The infection rate was

substantially lower than in tunneled CVCs. Therefore, the AVflo graft may

improve the clinical status of dialysis patients by decreasing the exposure

to CVCs.

J Vasc Access. 2013

HeRO Graft

HeRO Graft (Hemodialysis

Reliable OutFlow) is the ONLY

fully subcutaneous AV access

solution clinically proven to

maintain long-term access for

hemodialysis patients with central

venous stenosis.

ePTFE Graft

Beading (3-4cm) for kink resistance .

Orientation line on graft to guide

placement during tunneling. Titanium

connector

Silicone-Coated Reinforced Nitinol

No venous anastomosis

Reinforced 48 braid nitinol: kink &

crush resistant

Removable and replaceable

Radiopaque band (at distal tip)

HeRO Graft

HeRO Graft

HeRO Graft

Outcomes comparison of HeRO and lower extremity arteriovenous

grafts in patients with long-standing renal failure. Steerman SN, Wagner J, Higgins JA, Kim C, Mirza A, Pavela J, Panneton JM, Glickman MH

60 HeROs were placed in 59 patients and 22 LEAVGs were placed in 21 patients.

Mean follow-up was 13.9 months for the HeRO group and 11.9 months for the LEAVG group.

The HeRO patients underwent a mean of 6.3 previous tunneled dialysis catheter insertions and

3.1 previous AVG/arteriovenous fistula placements.

The LEAVG patients underwent placement of a mean of 4.1 previous tunneled dialysis catheters

and 2.6 previous AVG/arteriovenous fistulas.

The principal difference was the number of interventions to maintain patency, which was 2.21 per

year in the HeRO group and 1.17 per year in the AVG group (P = .003)

Secondary patency at 6 months was 77% for the HeRO patients and 83% for the LEAVG patients

(P = .14). The HeRO and LEAVG groups had no difference in infection rate per 1000 days (0.61

vs 0.71; P = .77) or mortality rate (22% vs 19% respectively; P = .22) at 6 months.

CONCLUSIONS:

In access challenged patients, LEAVG and HeRO offer similar rates of secondary patency,

infection, and all-cause mortality. The LEAVG required fewer interventions to maintain patency,

and the HeRO maintains the benefit of utilizing the upper extremity site of venous drainage. In our

practice, we prefer the HeRO to LEAVG, especially in patients with peripheral arterial disease and

in the obese population, because it preserves lower extremity access options.

J Vasc Surg. 2013 Mar;57(3):776-83;

Percutaneous interventions on the hemodialysis reliable outflow

vascular access device. Gebhard TA, Bryant JA, Adam Grezaffi J, Pabon-Ramos WM, Gage SM, Miller MJ,

Husum KW, Suhocki PV, Sopko DR, Lawson JH, Smith TP, Kim CY.

RESULTS:

The mean time from HeRO implantation to initial dysfunction or thrombosis was 171

days. In 60 (82%) procedures, the HeRO device was thrombosed. An intragraft

stenosis was the most common lesion identified (59%; n = 43) followed by an arterial

anastomosis stenosis identified in 18% (n = 13). In 22% (n = 16) of procedures in

which the HeRO device was thrombosed, an underlying cause was not identified after

thrombectomy. The 3-, 6-, and 12-month primary patency rates after intervention

were 47%, 37%, and 26% for first-time interventions. The secondary patency rates

were 80%, 70%, and 64%. The only complication was pulmonary embolism resulting

in death 2 days after HeRO thrombectomy.

CONCLUSIONS:

Percutaneous interventions on thrombosed and failing HeRO devices yielded

acceptable primary and secondary patency rates after intervention in these patients

with few, if any, alternatives for hemodialysis access.

J Vasc Interv Radiol. 2013 Apr;24(4):543-9.

La protesi biosintetica

Tubo di collagene ovino maturo sviluppato

attorno ad un modello di poliestere a rete

La rete in poliestere, parte integrante della

parete della protesi, è circondata ed

incapsulata dal collagene

Il collagene è sterilizzato con glutaraldeide

Retta e loop

Collagene

Poliestere Glutaraldeide

Biocompatibilità

Emocompatibilità

Durata

Elasticità

Non antigenico

Duraturo

La protesi biosintetica associa la biocompatibilità

delle protesi biologiche alla durata delle

sintetiche senza valvole e diramazioni

Accurato lavaggio

Anastomosi venosa e tunnel

Anastomosi arteriosa e finale

Sopravvivenza protesi

54

37

30

0

10

20

30

40

50

60

Basale Primaria 6 mesi Primaria 12 mesi

47 Osservati

7 Deceduti 45 Osservati

2 Deceduti

78.7%

66.6%

J Vasc Surg. 2011 Jul 29.

Conclusions of the study

From these results we believe that BBAVF

should be the first choice in patients with a good

life expectancy (2 years) and who can rely on an

available temporary VA, such as a central

venous catheter. However, given the shorter

time to use, AVG could be an alternative choice

in patients with compromised clinical conditions

and in whom a temporary VA is not reliable,

considering that the long-term outcome may be

considered beneficial regardless.

Morosetti M et al: J Vasc Surg. 2011 Jul 29.

A systematic review of cohort studies to

evaluate the associations between type of

vascular access (arteriovenous fistula,

arteriovenous graft, and central venous

catheter) and risk for death, infection, and

major cardiovascular events

Associations between hemodialysis access type and

clinical outcomes: a systematic review. Ravani P, Palmer SC, Oliver MJ, Quinn RR, MacRae JM, Tai DJ, Pannu NI, Thomas C, Hemmelgarn

BR, Craig JC, Manns B, Tonelli M, Strippoli GF, James MT.

In conclusion, persons using catheters for

hemodialysis seem to have the highest risks for

death, infections, and cardiovascular events

compared with other vascular access types, and

patients with usable fistulas have the lowest risk.

J Am Soc Nephrol. 2013 Feb;24(3):465-73

Effect of timing of the first cannulation on survival of

arteriovenous hemodialysis grafts. Feldman L, Shani M, Mursi J, Beberashvili I, Bass A, Weissgarten J, Rabin I

According to the time, in weeks, between graft construction and its

first successful cannulation, the grafts were divided into six groups:

2nd, 3rd, 4th, 5th, 6th and 7th or more week after surgery.

In the whole cohort, the incidence of primary graft failure at 12

months was 72.2%, and the incidence of cumulative graft failure at

12 months was 40.7%.

The incidences of primary graft failure and cumulative graft failure at

12 months did not differ significantly between the study groups.

In our study, timing of the first cannulation of a new arteriovenous

polytetrafluoroethylene graft had no significant impact on graft

survival.

Ther Apher Dial. 2013 Feb;17(1):60-4.

Conclusions: In our experience, the intensive

follow-up controls did not improve the

permeability of the Hax-AVF, although re-

operations due to obstruction did diminish.

The follow-up of these access fistulas should

be clinical based on hemodialysis data,

leaving ultrasonographic evaluation for

those cases where a malfunction is

suspected.

Grazie per l’attenzione !