Introduction

• 300 – 400: 1 000 000 worldwide

• CRD in Bulgaria is nearly twicehigher than the average for the EU -almost 26%

Morbidity of Chronic RenalDisease:

IntroductionPermanent vascular access

(PVA) includes all methods ofrealizing an arteriovenous

anastomosis (fistula) - AVF.

Complications of the AVF:

• hemodynamically significant stenosis;• infection of the PVA;

• thrombosis ;

• pseudoaneurism;• rupture of the PVA.

Introduction

Endovascular treatment ofPVA is a safer alternative of

the operative one.

Introduction

IntroductionHemodynamically significant stenosis is

present when the normal vasculardiameter is reduced by 50% or more.

• increased static or dynamic pressure;• decreased blood capacity;• groundless dialysis cleansing;• swallowing of the extremity.

Introduction

Stenosis found before it thromboses iseasier to be treated than post-

thrombotic one and shows 79%reliability. Reliability of post-

thrombotic treatment of the stenosisdecreases to 40%.

PTA

The preferred method of treatment foreither arterial or venous stenosis of PVA is

Percutaneous Transluminal Angioplasty(PTA).

PTAIndicator of dysfunction:

• greater than 25% decrease in flow over3-4 month period;

• elevated urea recirculation;• arm swelling;• poor thrill/pulsatile;• poor maturation of fistula.

PTA

Balloons:

• High-pressurenon-compliant;

• “Coronary”type balloons;

• Cuttingballoons;

• Oversizedballoons.

PTA + Stenting

Stenting combined with PTA isindicated when elastic stenosis is

present or relapse of stenosis for aperiod of 3 months.

Stents:

• Self-expandingstents;

• Bare stents;• Covered stents;• Balloon-

expandablestents.

PTA + Stenting

PTA

The typical endpoint is restoration ofnormal trill to the fistula. A successful

angioplasty will have complete effacementof the balloon waist and result in 0 - 30%

residual narrowing.

PTAContraindications:

• Infected AVF;• Uncorrectable severe coagulopathy;• Severe allergy to iodinated contrast

agents;• Percutaneous intervention on a

newly placed graft.

Treatment of clotted AVF is eitherendovascular thrombectomy (ET)

or thrombolysis.

Sweeping thrombus from the occludedgraft into the central venous circulation

Pulmonary circulation embolization

ET Balloon-Sweep

Contraindications:

• Patients with cardiopulmonarycompromise;

• Known right-to-left intracardiac shunt,especially with pulmonary hypertension.

ET Balloon-Sweep

Endovascular thrombectomy is mostcommonly performed by using

thromboaspiration, combined withangioplasty. It is most useful with

fresh thrombus .

ET Thromboaspiration

Mechanical thrombectomydevices are designed to removethrombus quickly, effectively,and safely from hemodialysis

grafts.

ET Devices

Recirculation-type devices create ahydrodynamic vortex, which homogenizes

the thrombus converting it into slurry.

ET Devices

Recirculation-type devices include:

• Helix• Xpeedior• Oasis catheter• Hydrolyser catheter• Thrombex PMT

ET Devices

The non-recirculation-type devices use arapidly spinning wire basket or plastic brush

to mechanically fragment the thrombus.

ET Devices

Non-recirculation-type devicesinclude:

• Trerotola-PTD• Thrombolytic brush catheter(Cragg/Castaneda)

ET Devices

Thrombolysis is taken in considerationmainly in combination with other methods

of endovascular treatment of PVA andespecially during the first couple of hours

after thrombosis.

Thrombolysis

Results

Immediate patency 3-month patency 6-month patency

Angioplasty 0 – 30% residualnarrowing

- 50%

Thrombectomy >85% 40% 20 - 40%

Short-term results:

Results

Long-term patency of vascular access isdependent on the identification and

successful treatment of all significantstenoses.

Long-term Results:

Long-term results should be consideredonly when angioplasty with/without

stenting is performed.

Results

Endovascular therapy requires qualifiedmedical team and adequately equippedoperating room. The medical supplies

needed for these procedures are expensiveand in this sense endovascular treatment

of AVF in Bulgaria is financiallycompromised.

Conclusion

References1. Handbook of Angioplasty and Stenting

Procedures, Techniques in IR series, LeeWatkinson;

2. Съдов достъп. Перитонеална диализа, проф.Д-р Здравко Краев;

3. Dialysis Access: A Multidisciplinary Approach ,Richard James Gray,Jeffrey J. Sands;Endovascular Interventions: A Case-BasedApproach, Robert S. Dieter,Raymond A. Dieter,Jr. ,Raymond A. Dieter, III,AravindaNanjundappa

4. Vascular Surgery, SIXTH EDITION, Robert B.Rutherford MD, FACS, FRCS (Glasg.)

5. Haimovici's Vascular Surgery, 6th Edition

Thank you for yourattention!

???Questions ???