state of the art & future trends: an italian’s...
TRANSCRIPT
Hemodialysis angioaccesses
State of the art & future trends:
AN ITALIAN’S PERSPECTIVE
Nicola Pirozzi
Department of Clinical and Molecular Medicine “Sapienza” University of Rome
Disclosure
Speaker name: Nicola Pirozzi
.................................................................................
I have the following potential conflicts of interest to report:
Consulting (BARD)
Employment in industry
Shareholder in a healthcare company
Owner of a healthcare company
Other(s)
I do not have any potential conflict of interest
X
- ITALIAN REGISTRY
- epidemiology
- treatments
- outcomes
- “NEFROLOGIA INTERVENTISTICA”
- PERSONAL EXPERIENCE
TOPICS
ITALIAN REGISTRY
Incidence : 160 pmp
Prevalence : 800 pmp
Incident >72y: 50%
Prevalent > 74y: 36%
HTA DM VASCULOPATY
CO-MORBIDITY
FUTURE CHALLENGES
• PATENCY OF
ARTERIES AND VEINS
• HAIDI
• HIGH FLOW
Incident patients - type of vascular access
Central venous catheter 48.5% (in 2002: 23%)
Arterio-venous fistula 51.5% (in 2002: 76%)
AV graft <1%
C
V
C
A
V
F
Prevalent patients - type of vascular access
CVC 19.7% (in 2002: 6%)
AVF 78.5% (in 2002 : 92%)
AV graft <3% (in 2002 <3%)
C
V
C
A
V
F
AUTOLOGOUS ARTERIO-VENOUS FISTULA (AVF)
78.5% OF PREVALENT PTS
Distal AVF 88%
Proximal AVF 12%
Elderly, diabetic and dialysis vintage >10y included
Modified from L.Turmel Rodrigues, Marseille 2012, http://www.sfav.org/Publication/SFAV2012/002.pdfModified from L.Turmel Rodrigues, Marseille 2012, http://www.sfav.org/Publication/SFAV2012/002.pdf
Global median survival 70 month
(50% cardiac death)
0 5 10
Years
75%
50%
25%
Su
rviv
al
> 65y
< 65y
“NEFROLOGIA INTERVENTISTICA”
- Creation and maintenance of vascular access for haemodialysis
AVF, AVG, CVC
+/- Color Doppler ultrasound of VA
+/- Radiologic endovascular procedure
- US interventional nephrology: only endovascular/ CVCprocedure -
“NEFROLOGIA INTERVENTISTICA”
- Nephrology post graduate course
Includes training in vascular access care
Interventional skills formally requested as accademic core curriculum
- AVF-AVG creation and manteinance
- CVC implant
- US (CDU)
Radiologic endovascular procedure not included
“NEFROLOGIA INTERVENTISTICA”
PERSONAL EXPERIENCE
“Nephrologist” + Interventional Nephrologist
Vascular access training in Paris
- VA surgery, microsurgery
- Endovascular treatment of complication
Exercing since 2000 (>1000 procedures)
VA care “up to date 2013”:
12 dialysis centres ( 600 patients)
+ nephrology dpts
+ non-ESRD indications
228 procedures/2013
PERSONAL EXPERIENCE
OPERATIVE PROTOCOL
Out-patient evaluation 1/ week (dedicated database)
First evaluation, follow-up after surgery (1w, 1m, 1y), complications
- Clinical and CDU evaluation
Indication and list for surgery or endovascular procedure
- 2 session /week (surgery/endovascular)
+ emergencies…
PERSONAL EXPERIENCE
Technical
- preoperative US evaluation
- loco-regional anesthesia (prolonged vasoplegia)
- preventive haemostasis (time, blood, wound sparing)
- operative microscope (because it is microsurgery!)
Clinical
- as distal as possible (snuff-box and ulnobasilic AVF included) :
• eventual secondary endovascular-assisted maturation
• superficialisation (lipectomy) in obese
• prevention of ischemia, high-flow
- avoid CVC as much as possible
PERSONAL “guidelines”
Future of VA care: challenging task
- Growing ESRD population
- “difficult” patients
- ↑ need of dedicated specialist
- Forearm Fistula First (low rate of complications, easy to treat)
Nefrologia Interventistica: a good way?
CONCLUSION
