early cannulation a new model in delivering hemodialysis

ASVSIstanbul 2013

Early cannulation, a new model in delivering hemodialysis

Jürgen Falkensammer

Department of Vascular and Endovascular Surgery

Wilhelminenspital Wien

Falkensammer ASVS Istanbul 2013

Disclosures

Jürgen Falkensammer, MD

I have the following potential conflicts of interest to report:

Honorarium for the presentation

Epidemiology of RRT


USRDS 2013

Access Types


incident prevalent

DOPPS, Kidney Int. 2002

HD catheters


• High morbidity caused by

− Thrombosis

− Infection

K/DOQI 2006

Patient Survival


Dhingra et al, Kidney Int. 2001

diabetic Non - diabetic

Adjusted for age, race, gender, BMI, history of smoking, PVD, CAD, CHF, neoplasm, ability to ambulate and education level

Relative risk of death compared to AVF


Dhingra et al, Kidney Int. 2001

Adjusted for age, race, gender, BMI, history of smoking, PVD, CAD, CHF, neoplasm, ability to ambulate and education level

HD catheters


• High morbidity caused by

− Thrombosis

− Infection

• Risk for permanent central venous stenosis or occlusion

• Discomfort and cosmetic disadvantage of an external appliance

• Shorter expected use-life than other access types• Overall lower BFRs, requiring longer dialysis times

K/DOQI 2006

K/DOQI Guidelines


• Short-term catheters should be used for acute dialysis and for a limited duration in hospitalized patients

Short-term Catheters should not be used in patients with foreseeable chronic HD dependency

K/DOQI 2006

K/DOQI Guidelines


• Avoid if possible: Long-term catheters

Alternative to long-term catheters?

K/DOQI 2006

K/DOQI Guidelines


Order of preference for HD access:• radial-cephalic AVF• brachial-cephalic AVF• brachial-basilic transposed AVF +/-• forearm AVG• upper arm AVG• alternative sites

Graft Survival


DOPPS, Kidney Int. 2002

K/DOQI Guidelines


Fistula First Strategy

If a primary AVF can not be established, a synthetic AV graft is the next preferred type of vascular access.

Requirements for AV Grafts


• Easy to implant• Good incorporation• Do not clot• Infection resistant• Easy to cannulate• Does not bleed after cannulation

• Does not form pseudoaneurysms

Requirements for early-cannulation Grafts


• Does not weep• Is self-sealing• < 24 hours cannulation

Early-access Grafts


Vectra® Vascular Access Graft

AVflo™ Vascular Access Graft

Gore® Acuseal Vascular Graft

Flixene™ Atrium

Rapidax TM

Polyuretane vs. PTFE

Early-access Grafts


Multilayered:

Outer layer for tissue integration

Intermediate layer for sealing

Inner layer for blood contact

Special features

Design

Antithrombotic properties

Infection - resistance

Vectra® by Bard


Polyurethane

Microporous Outer Layer

Monofilament Reinforcement

Self-Sealing Middle Layer

Microporous Inner Layer

AVflo™by Nicast


Polyurethane

Outer Layer – tissue integration

Middle Layer – self-sealing

Barrier Layer – prevents weeping

Middle Layer – self-sealing

Inner Layer – minimizes platelet adhesion

Gore® Acuseal


PTFE

PTFE

Silicone

CARMEDA® BioActive Surface (Heparin)

Flixene™ by Atrium


PTFE

Tissue Surface

HydrostaticProtectionMembrane

Flow surface

Flixene™ - Special Features


Resistance

Tapered design

Graduated wall thickness

Flixene™ by Atrium


Low – profile tunneling system

Flixene™ IFG


AVF vs. PTFE graft


Patency of autogenous and PTFE upper extermity AV hemodialysis access: A systematic review(Huber et al, JVS 2003)

• Medline-based systematic literature review and meta-analysis of patency data in life table or KM

• 1966-2001: 211 full text articles identified • 34 studies fulfilled the criteria

Huber et al, JVS 2003

18 – Months Patency Rates


6 months 18 months

Primary patency

AVF 72% 51%

AVG 58% 33%

Secondary patency

AVF 86% 77%

AVG 76% 55%

Huber et al, JVS 2003

6 – Months Patency Rates


AVF PTFE Flixene Vectra AVflo

Author Huber et al, JVS 2003 Schild AF et al, J Vasc

Access 2011

Kakkos et al. J Vasc Surg

2008

Wijeyaratne et al, J Vasc Access 2011

N = 1849 1245 33 76 35

Primary patency 72% 58% 49% 75% 73%

Secondary patency 86% 76% 80% 85% 82%

Primary assisted patency!

Indications for early – cannulation AV grafts


• early access• to avoid a HD catheter• as a revision graft / for interposition: no

‚catheter – bridging‘ needed• possibly whenever no native vessels are

available for fistula creation

>> indication for a ‚conventional‘ access graft?

early cannulation a new model in delivering hemodialysis

Education

avffalkensammer asvs

disclosuresjrgen falkensammer

hd access

untere rechte ecke

ziehen sie zum ndern

high morbidity

history of smoking

dhingra et