my av access maintenance algorithm

My AV Access Maintenance

Algorithm

Tobias Steinke, MDHead of Vascular and Endovascular Surgery

Schoen Klinik Dusseldorf

Dusseldorf, Germany

DisclosuresDr. med. Tobias Steinke

I have the following potential conflicts of interest to report:

❑ Consulting: Bard, BD, TVA Medical, Merit Medical, Medtronic

❑ Employment in industry

❑ Stockholder of a healthcare company

❑ Owner of a healthcare company

❑ Other(s)

❑ I do not have any potential conflict of interest

✓

2 LINC 2021 | AV Symposium | 500568 | 01/2021


No AV Access Lasts Forever

▪AVF maturation failure remains an important clinical problem ESRD

patients

▪ Failure rates in observational studies range from 20-60%1, 2

▪A multicenter RCT in the US reported that up to 60% of AVFs created

failed to mature successfully for dialysis use3

▪Typical complications in the are stenoses, thromboses, aneurysms and

infections.

▪ In ePTFE grafts 12-month secondary functional patencies are approximately

65%4

1. Allon M, Robbin ML. Kidney Int. 2002;62(4):1109-1124.

2. Allon M. Clin J Am Soc Nephrol. 2007;2(4):786-800.

3. Dember LM, Beck GJ, Allon M, et al. JAMA. 2008;299(18):2164-2171.

4. Huber TS, Carter JW, Carter RL, Seeger JM. J Vasc Surg 38: 1005–1011, 2003


Dysfunctional AV Access

▪Stenosis

▪Thrombosis

▪Aneurysm

▪Infection

Image courtesy Tobias Steinke, MD


AV Access: Infections

▪ Infection accounts for approximately 20 percent of hemodialysis AV

access loss.

▪The vascular access is the source of the majority of bacteremia in

hemodialysis patients.

▪Staphylococcus aureus and, less commonly, Staphylococcus epidermidis

are the predominant pathogens.

1. Invasive methicillin-resistant Staphylococcus aureus infections among dialysis patients--United States, 2005. Centers for Disease

Control and Prevention (CDC).

2. MMWR Morb Mortal Wkly Rep. 2007;56(9):197.

3. Fysaraki M et al. Int J Med Sci. 2013;10(12):1632-8. Epub 2013 Sep 20.

4. Nguyen DB et al.Clin Infect Dis. 2013;57(10):1393. Epub 2013 Aug 19.

5. D'Amato-Palumbo S et al. Oral Radiol. 2013 Jan;115(1):56-61.

6. Crowley L et al. Nephron Clin Pract. 2012;120 Suppl 1:c233-45. Epub 2012 Sep 01.

7. Anderson JE et al. ASAIO J. 2000;46(6):S18.

8. Nassar GM, Ayus JC. Semin Dial. 2000;13(1):1.

9. Nassar GM, Ayus JC. Am J Kidney Dis. 2002;40(4):832.


AV Access: Risk Factors for Infections

▪Pseudoaneurysms

▪Hematomas (often due to inappropriate graft cannulation),

▪Severe pruritus and scratching over needle sites,

▪Use of hemodialysis fistulas as a route of access for injection drug abuse

▪Manipulation of the access during secondary surgical procedures

An underappreciated infective complication is the clinically silent infection of a clotted

AV graft that is no longer being used.

1. Invasive methicillin-resistant Staphylococcus aureus infections among dialysis patients--United States, 2005. Centers for Disease

Control and Prevention (CDC).

2. MMWR Morb Mortal Wkly Rep. 2007;56(9):197.

3. Fysaraki M et al. Int J Med Sci. 2013;10(12):1632-8. Epub 2013 Sep 20.

4. Nguyen DB et al.Clin Infect Dis. 2013;57(10):1393. Epub 2013 Aug 19.

5. D'Amato-Palumbo S et al. Oral Radiol. 2013 Jan;115(1):56-61.

6. Crowley L et al. Nephron Clin Pract. 2012;120 Suppl 1:c233-45. Epub 2012 Sep 01.

7. Anderson JE et al. ASAIO J. 2000;46(6):S18.

8. Nassar GM, Ayus JC. Semin Dial. 2000;13(1):1.

9. Nassar GM, Ayus JC. Am J Kidney Dis. 2002;40(4):832.



Pus

Skin Necrosis

Pseudoaneurysm




PTFE graft lesion from

repeated cannulation

in the same area

Pseudoaneurysm

Images courtesy Tobias Steinke, MD


AV Access: InfectionsKDOQI Guidelines

Treatment

▪ 16.5 KDOQI considers it reasonable to consider for infected AV-access the rapid

initiation of empiric broad spectrum antibiotics and timely referral to a surgeon

knowledgeable in the management of vascular access complications (Expert

Opinion)

▪ 16.7 KDOQI considers it reasonable that the specific surgical treatment for AV-

access infections (with concurrent antibiotics) should be based on the patient’s

individual circumstances considering the extent of infection, offending organism,

and future vascular access options (Expert Opinion)

Lok CE, Huber TS, Lee T, et al. Am J Kidney Dis 2020;75:S1-S164.



▪Stenosis

▪Thrombosis

▪Aneurysm

▪Infection



AV Access: AneurysmsWhen to Treat?

Monitor closelyRevision should be

considered

Size Constant, not enlarging Enlarging

SkinMobile, soft, pinched

easilyShiny, thin, depigmented

Skin lesions None Ulcers, scabs

Arm elevation Collapses Pulsatil / may not collapse

Bleeding at

puncture sitesUncommon Prolonged bleeding times


AV Access: Aneurysms


Aneurysm of a brachio-basilic AVF



Exposure and resection

of the aneurysm End to end anastomsisImage courtesy Tobias Steinke, MD



Aneurysm of a brachio-cephalic AVF





There is no endovascular option

…


AV Access: AneurysmsKDOQI Guidelines

▪ 17.8 KDOQI considers it reasonable that surgical management is the preferred treatment for patients with

symptomatic, large or rapidly expanding AV-access aneurysm/pseudoaneurysm (see below “definitive treatment”)

(Expert Opinion)

▪ 17.9 KDOQI considers it reasonable that a definitive surgical treatment is usually required for anastomotic

aneurysms/pseudoaneurysms (Expert Opinion).

▪ 17.10 KDOQI considers it reasonable that open surgical treatment should be deemed the definitive treatment for

AV-access aneurysms/pseudoaneurysms with the specific approach determined based upon local expertise (Expert

Opinion).

▪ 17.11 KDOQI considers it reasonable to use covered intraluminal stents (stent-grafts) as an alternative to open

surgical repair of aneurysms/pseudoaneurysms only in the special circumstances such as patient contraindication to

surgery or lack of surgical option, due to the associated risk of infection in this scenario (Expert Opinion).

▪ 17.12 KDOQI considers it reasonable that should a stent-graft be used to treat aneurysm/pseudoaneurysm, that

cannulation over the stent-graft segment be avoided when possible (Expert Opinion)

Lok CE, Huber TS, Lee T, et al. Am J Kidney Dis 2020;75:S1-S164.



▪Stenosis

▪Thrombosis

▪Aneurysm

▪Infection


cephalic archcentral venous

stenosis

venous

anastomosis (AVG)

venous outflow juxta-anastomotic


AV Access: StenosesLocations

Rajan, DK, et al. Radiology 2004;232:508-515.

Juxtanastomotic, 64%

Brachiocephalic /

elbow AVFTransposed

brachiobasilic AVF

Radiocepahlic /

Cimino AVF

Cephalic arch, 50%

Swingpoint, 74%


Treatment

Management of autogenous AVF stenosis

▪Relevant stenosis

▪Stenoses should be treated if the diameter is reduced by >70% and is

accompanied with a reduction in access flow or in measured dialysis dose.

Management of AVG stenosis

▪Relevant stenosis

▪Stenoses should be treated if the diameter is reduced by >50% and is

accompanied with a significant decline of access flow.


Factors Influencing Treatment Decisions

Clinically relevant or symptomatic stenosis

AV access stenosis should be treated when it is

hemodynamically, functionally and clinically significant in

an individual patient, suggested by one or more of the

following:

▪ Decreased access flow

▪ Deteriorating venous and/or arterial pressure

▪ Decrease in dialysis adequacy

▪ Pulsatility/flaccid access

▪ Change in thrill/change in bruit

▪ Arm/hand/neck swelling

▪ Prolonged bleeding

▪ Difficult puncture

▪ Recirculation

Patient factors Fistula factors

▪ Patient fitness, prognosis or

life expectancy

▪ The anatomical location of

the stenosis within the fistula

▪ The number and type of

previous interventions to

address the stenosis

If a patient requires ≥4 interventions in the same stenosis in a 12-month period (or ≥3 interventions in 6 months if

this occurs sooner) a multi-disciplinary team and patient discussion on access options should be triggered

Gibbs, P. UK Expert Consensus Approach for Managing Symptomatic AVF Stenosis in HD patients. VASBI 2019.


Management of Clinically-Relevant or Symptomatic Stenoses in Mature AVFBy Anatomical Site

▪ Inflow segment, defined as the perianastomotic artery

▪Anastomosis and juxta-anastomotic venous segment (up to 5 cm)

▪Cannulation zone

▪Outflow segment

▪Cephalic arch

▪Central venous region

Gibbs, P. UK Expert Consensus Approach for Managing Symptomatic AVF Stenosis in HD patients. VASBI 2019.

LINC 2021 | AV Symposium | 500568 | 01/2021

Surgical Results After Patch Reconstruction of AV Access StenosisPatency Depends on the Anatomical Site of Reconstruction

0

10

20

30

40

50

60

70

80

90

100

4 months 8 months 12 months

venous anastomosis of graft

stenosis distal to anastomosis

in combination with aneurysm

Brittinger WD, Anschl. Verfahren an die künstliche Niere, 2005;6

arterial anastomosis

pa

ten

cy


AV Access Stenoses: Cutting Balloons

Saleh HM, et al. J Vasc Surg.2014 Sep;60(3):735-40.

Venous Stenosis

No significant differences in assisted primary

patency rates were identified (p=0.360)

Arterial Anastomotic Stenosis

No significant differences in assisted primary

patency rates were identified (p=0.921)


AV Access Stenoses: Bare Metal Stents

Neuen BL et al. Int J Vasc Med 2015;2015.


European Best Practice GuidelinesRecommendations for Treatment of Stenoses By Anatomical Site

Class LevelMy

algorithm

Arterial InflowBalloon angioplasty is recommended as primary treatment

for inflow arterial stenosis of any type of vascular accessI C

Juxta-Anastomotic

(Forearm)

Surgical proximal relocation of the vascular access

anastomosis should be considered in juxta-anastomotic

stenosis in the forearm

IIa C

Venous OutflowBalloon angioplasty is recommended for the treatment of

venous outflow stenosisI C

Cephalic ArchEndovascular treatment with stent grafts should be

considered for the treatment of cephalic arch stenosisIIa B

Schmidli J, Widmer MK, Basile C, et al. Eur J Vasc Endovasc Surg 2018;55:757-818.



Class LevelMy

algorithm


for inflow arterial stenosis of any type of vascular accessI C Stent

Juxta-Anastomotic

(Forearm)




IIa C








Class LevelMy

algorithm



Juxta-Anastomotic

(Forearm)




IIa C







Literature: Radiocephalic AVF Primary Patency Rates Through 1 YearPeri-anastomotic/Juxta-anastomotic Stenoses in Non-Thrombosed AVF

Manuscript TechniquePrimary Patency

Through 12 Months

Mean patients

age (years) Diabetics (%)

Tessitore 20061

Surgery

(n=21)91% 56 19

PTA

(n=43)54% 62 21

Long 20112

Surgery

(n=21)71% 65 33

PTA

(n=52)41% 71 42

1. Tessitore N et al. Clin J Am Soc Nephrol. 2006 May;1(3):448-54. doi: 10.2215/CJN.01351005.

2. Long B et al. J Vasc Surg 2011;53(1):108–14. doi: 10.1016/j.jvs.2010.08.007.


Target Lesion Primary Patency Through 6 MonthsDCB vs PTA by Lesion Location

IN.PACT AV DCB is approved in the USA, Canada, and Japan for treatment, after

appropriate vessel preparation, of obstructive lesions up to 100 mm in length in the

native arteriovenous dialysis fistulae with reference vessel diameters of 4 to 12 mm.

Lookstein, R. VIVA 2020



Class LevelMy

algorithm



Juxta-Anastomotic

(Forearm)




IIa C DCB








Class LevelMy

algorithm



Juxta-Anastomotic

(Forearm)




IIa C DCB


venous outflow stenosisI C DCB






Class LevelMy

algorithm



Juxta-Anastomotic

(Forearm)




IIa C DCB







Literature: 6-month Primary Patency Rates in Non-Thrombosed Fistulas Cephalic Arch Stenoses

Author TechniqueNumber of

Patients

Primary Patency

Through 6 Months

Shemesh 20081Stent graft 13 82%

BMS 10 39%

Miller 20182

Stent graft 50 74% ± 12%

Historic BMS 50 29% (17% - 42%)

Historic PTA 50 27% (9% - 30%)

D‘Cruz 2019

Meta-analysis

Stent graft 157 82.7%

BMS 114 52.2%

PTA 202 23.3%

1. Shemesh D et al. Journal of Vascular Surgery 2008;48(6):1524-31, 1531.e1-2.

2. Miller GA et al. Journal of Vascular Surgery 2018;67(2):522–8.

3. D’Cruz RT et al. J Vasc Access 2019;20(4):345–55.


Target Lesion Primary Patency Through 6 MonthsDCB vs PTA by Lesion Location

IN.PACT AV DCB is approved in the United States, Canada, and Japan for treatment, after appropriate vessel preparation, of obstructive lesions up to 100 mm in

length in the native arteriovenous dialysis fistulae with reference vessel diameters of 4 to 12 mm.

Lookstein, R. VIVA 2020



Class LevelMy

algorithm



Juxta-Anastomotic

(Forearm)




IIa C DCB




considered for the treatment of cephalic arch stenosisIIa B DCB


Conclusion


AV Access Maintenance Algorithm

Aneurysm Pseudoaneurysm Rupture Stenosis

PTA

High

pressure

PTA

Surgery Covered StentRestenotic

lesionDCB

Patient History

Characteristics

Gender, Age ♂, 66+, ESRD / CVC

Comorbidities

Coronary heart disease

Atrial fibrilation

Oral anticoagulation

Diabetes mellitus

COLD

History of AV Access04-2019 CVC for hemodialysis

04-2019 surgical radio-cephalic-fistula


Lesion Characteristics

Characteristics

Target Arm left

Lesion Access retrograde ultrasound controlled

Fistula Location forearm

Lesion Location Juxta-anastomotic

AVF Type radiocephalic

Lesion Length 3.8 cm

Percent Stenosis 70%

Calcification none

Thrombus none


Ultrasound-guided Retrograde Puncture:

Images Courtesy Tobias Steinke, MD


Diagnostic Angiography:



POBA / HP:

POBA, 6/40



POBA / HP / Full Inflation:

POBA, 6/40



Check Result of HP- POBA:Before PTA



DCB:

Choose a longer DCB!

Cover POBA treatment area at least

completely

POBA, 6/40

DCB, 7/60



Retrograde Angio Post-DCB:Before

intervention

Image after

treatment



Images Before and After Intervention:

Before intervention Image after treatmentImages Courtesy Tobias Steinke, MD


my av access maintenance algorithm

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