AV Fistula AV Fistula Creation by a US Creation by a US Interventional Interventional NephrologistNephrologist

Rick Mishler, MD, FACPRick Mishler, MD, FACPInterventional NephrologistInterventional Nephrologist

AKDHC Surgery CenterAKDHC Surgery CenterPhoenix, AZPhoenix, AZ

Analysis of Initial Analysis of Initial ExperienceExperience

Annual Dialysis ConferenceAnnual Dialysis Conference

San Francisco, CASan Francisco, CA

February 26, 2006February 26, 2006

Back GroundBack Ground

US nephrologist currently with 8 years of US nephrologist currently with 8 years of interventional experienceinterventional experience

Trained in autologous fistula creation by a US Trained in autologous fistula creation by a US vascular surgeon for several months vascular surgeon for several months

Setting: ambulatory surgery center that Setting: ambulatory surgery center that provides comprehensive vascular access careprovides comprehensive vascular access care

Additional training with a European Additional training with a European nephrologistnephrologist

117 consecutive avf creations in 116 patients 117 consecutive avf creations in 116 patients as solo operatoras solo operator

September 2004-September 2005September 2004-September 2005

DemographicsDemographics

64.1 (23-88) years average patient age 64.1 (23-88) years average patient age

45 (39%) female45 (39%) female

61 (52 %) of the patients were diabetic61 (52 %) of the patients were diabetic

Patient CKD StagePatient CKD Stage

71 (61%) - stage 571 (61%) - stage 5

43 (37%) - stage 443 (37%) - stage 4

2 patients stage 3 2 patients stage 3

ProcedureProcedure

Performed in vascular access ASC OR Performed in vascular access ASC OR Versed and fentanyl conscious sedation Versed and fentanyl conscious sedation Oxygen by nasal canulaOxygen by nasal canula RN administered meds and monitored ptRN administered meds and monitored pt Surgical scrub technician assisted Surgical scrub technician assisted Average procedure length: 74 (46-133) Average procedure length: 74 (46-133)

minutesminutes Average systemic heparin dose was 3831 Average systemic heparin dose was 3831

unitsunits

Locations of the Locations of the AnastomosesAnastomoses

18% radial artery-cephalic vein 18% radial artery-cephalic vein anastomosisanastomosis 19 left19 left 2 right2 right

82% brachial artery - cephalic, 82% brachial artery - cephalic, basilic or perforating vein basilic or perforating vein anastomosis anastomosis 81 left81 left 15 right 15 right

Vessel sizes Vessel sizes

Measurements from preoperative Measurements from preoperative ultrasound vessel mapping (108/116)ultrasound vessel mapping (108/116)

Artery: 4.1mm (82% brachial artery)Artery: 4.1mm (82% brachial artery)

Vein: 3.6 mmVein: 3.6 mm

ComplicationsComplications

4 brachial artery avf caused steal 4 brachial artery avf caused steal syndromesyndrome 2 were banded with relief of symptoms and 2 were banded with relief of symptoms and

are in use for dialysis are in use for dialysis 1 access was ligated with relief of symptoms1 access was ligated with relief of symptoms 1 avf had mild symptoms and no treatment1 avf had mild symptoms and no treatment All 4 were managed by IN in the AKDHC SCAll 4 were managed by IN in the AKDHC SC

No ER visits or hospitalizations occurred No ER visits or hospitalizations occurred as a result of the access surgeryas a result of the access surgery

US SurveillanceUS Surveillance

6 wks post 6 wks post creationcreation

77/117(66%) 77/117(66%) obtainedobtained

70/77 (91%) 70/77 (91%) maturingmaturing

5/77 5/77 (6%)thrombosed(6%)thrombosed

2 lost to follow up2 lost to follow up

12 wks post 12 wks post creationcreation

64/117(55%) 64/117(55%) obtainedobtained

54/64 (46%) 54/64 (46%) maturingmaturing

7/64 (6%) not 7/64 (6%) not mat.mat.

3 3 (4.6%)thrombosed(4.6%)thrombosed

Interventions Interventions 12 (10%) accesses thrombosed12 (10%) accesses thrombosed

5 underwent endovascular thrombolysis/pta 5 underwent endovascular thrombolysis/pta 1 was successful 1 was successful

28 (24%) avf required other intervention 28 (24%) avf required other intervention with pta and/or accessory drainage vein with pta and/or accessory drainage vein occlusion(6). occlusion(6).

2 of these were subsequently abandoned2 of these were subsequently abandoned 34/40 (85%) interventions yielded avf that 34/40 (85%) interventions yielded avf that

continued to function/mature (Kian et. al., continued to function/mature (Kian et. al., KI, 2006)KI, 2006)

““Surgical” RevisionsSurgical” Revisions

1 brachial-cephalic avf was created 1 brachial-cephalic avf was created when the initial radial-cephalic avf when the initial radial-cephalic avf failedfailed

5 basilic vein avf required 5 basilic vein avf required transposition and 2 of these have transposition and 2 of these have been accomplishedbeen accomplished

2 juxta-anastomotic segments may 2 juxta-anastomotic segments may require revisionrequire revision

2 avf may require superficialization2 avf may require superficialization

Longitudinal DataLongitudinal Data

Average follow up: 287 (157-516) daysAverage follow up: 287 (157-516) days

Mean follow up: 346 daysMean follow up: 346 days

Average to cannulation: 149 (29-427) Average to cannulation: 149 (29-427) days (CKD + ESRD avf)days (CKD + ESRD avf)

Mean to cannulation: 228 days Mean to cannulation: 228 days (CKD+HD avf)(CKD+HD avf)

Current Status of AVFCurrent Status of AVF

47% became active47% became active HDHD CKD w/ US maturityCKD w/ US maturity Died w/ active avfDied w/ active avf

42% are maturing42% are maturing HDHD PDPD CKDCKD

11% failed11% failed

Current Status of AVFCurrent Status of AVFDetailDetail

43 (37%) are in use for dialysis43 (37%) are in use for dialysis 2 patients died with active avf2 patients died with active avf 9 (8%)CKD but OK to cannulate by US9 (8%)CKD but OK to cannulate by US 45 (38%)maturing45 (38%)maturing

21 remain CKD and developing21 remain CKD and developing 22 HD ESRD using an alternative access22 HD ESRD using an alternative access 2 PD ESRD2 PD ESRD

5 (4%) patients died w/ developing 5 (4%) patients died w/ developing access access

13 (11%) avf failed and are abandoned13 (11%) avf failed and are abandoned

PerspectivePerspective

0

1000

2000

3000

4000

5000

6000

Mishler

Konner

Mishler 185

Konner 5072

# of VAP

ConclusionsConclusions:: Given adequate experience and training in Given adequate experience and training in

the proper environment, it is possible for a the proper environment, it is possible for a US nephrologist to create av fistulae with US nephrologist to create av fistulae with satisfactory patent and access outcomes.satisfactory patent and access outcomes.

It seems likely that the results were It seems likely that the results were enhanced given the availability and enhanced given the availability and implementation of ultrasound surveillance implementation of ultrasound surveillance and endovascular procedures.and endovascular procedures.

This concept requires further validation by This concept requires further validation by other centers.other centers.

THANK YOU TO:THANK YOU TO:

Gerald Beathard, MD, PhDGerald Beathard, MD, PhD

Henry Tarlian, MDHenry Tarlian, MD

Klaus Konner, MDKlaus Konner, MD

Kam Takesian, RNKam Takesian, RN