What is new, in the new ESVS vascular access- clinical ......Topic KDOQI European (ERA/EDTA) New European (ESVS) Access-induced ischaemia Patients with an AVF should be assessed on

What is new, in the new ESVS vascular access-clinical practice guidelines?

Jan Tordoir, Maastricht

Faculty Disclosure

Jan H.M. Tordoir

I have no financial relationships to disclose.

▪ 9 chapters

▪ 78 recommendations

▪ 652 references


Volume 55, Issue 6, Pages 757–818

Topic KDOQI European (ERA/EDTA) New European (ESVS)

Evaluation for access placement

History and physical examination, and Duplex ultrasound of the upper-extremity arteries and veins

Clinical evaluation and non-invasive ultrasonographyof upper extremity arteries and veins

Patients should be examined prior to surgery with a tourniquet in a warm room and the proposed site of an arteriovenous fistula should be marked pre operatively

In adults when the inner radial arterial diameter is less than 2.0 mm and/or the cephalic venousdiameter is less than 2.0 mm by ultrasound measurement an alternative site for access shouldbe considered

If there is an indwelling central venous catheter or pacemaker the vascular access should be created in the opposite arm because of the risk of centralvenous stenosis and reduced access patency

Preferred access type

AVF preferred, AVG acceptable, CVC avoid if possible

Autogenous arteriovenous fistulae should be preferred over AV grafts and AV grafts should be preferred over CVC

An autogenous arteriovenous fistula is recommended as the primary option for vascularaccess

Access location

As distal as possible The upper extremity arteriovenous fistula should be the preferred access and should be placed as distal as possible

Regional anaesthesia should be considered in preference to local anaesthesia for vascular access surgery because of a possible improvement in access patency rate

Vascular access-clinical practice guidelinesPreop assessment & Strategy

Regional Versus Local Anaesthesia for HaemodialysisArteriovenous Fistula Formation

A Systematic Review and Meta-Analysis



Follow-up of VA

placement

If a fistula fails to mature by 6 weeks, a fistulogram or other imaging study should be obtained to determine the cause of the problem

Fistula maturation should be monitored to allow pre-emptive intervention if needed

If an arteriovenous fistula fails to mature by 6 weeks,additional investigations (like duplex ultrasound) should be considered in order toachieve prompt diagnosis and treatment

Timing of cannulation

AVF should be mature, ready for cannulation with minimal risk for infiltration, and able to deliver the prescribed blood flow Fistulae are more likely to be useable when they meet the Rule of 6s characteristics: flow greater than 600 mL/min, diameter at least 0.6 cm, no more than 0.6 cm deep, and discernible margins

An autogenous fistula should be cannulated when adequate maturation has occurred

Arteriovenous fistulas should be considered forcannulation 4-6 weeks after creation, and standard arteriovenous grafts after 2-4 weeks

Access care before cannulation

Access care after needle withdrawal

Access monitoring

Organized monitoring/surveillance approach with access flow as the preferred method

Objective monitoring of access function should be performed at a regular base by measuring access flow

Surveillance of arteriovenous fistulas with duplex ultrasound at regular intervals and pre-emptiveballoon angioplasty should be considered to reducethe risk of arteriovenous fistula thrombosis

Surveillance of arteriovenous grafts with duplex ultrasound at regular intervals and pre-emptiveballoon angioplasty is not recommended to preventthrombosis or improve arteriovenous graft functionality

Vascular access-clinical practice guidelinesCannulation & Monitoring

Access thrombosis

Access loss

Pre-emptive vs “wait and see” AVF

Am J Kidney Dis 2016; 67(3):446-460


Pre-emptive vs “wait and see” AVG

Access thrombosis

Access loss

Am J Kidney Dis 2016; 67(3):446-460


Topic KDOQI European (EDTA/ERA) New European (ESVS)

Treatment of thrombosis

Thrombosed autogenous and graft fistulae should be treated either by percutaneous or surgical thrombectomy

Thrombosed autogenous and graft fistulae should be treated either by interventional radiology or surgery. Individual centers should review their results and select the modality that produces the best results for that centre

Treatment of vascular access thrombosis shouldinclude perioperative diagnosis and treatment of any associated stenosis

Stenosistreatment

A fistula with a greater than 50% stenosis in eitherthe venous outflow or arterial inflow, in conjunctionwith clinical or physiological abnormalities, shouldbe treated with PTA or surgical revision

For venous outflow stenosis percutaneoustransluminal angioplasty (PTA) is the first treatment option

Balloon angioplasty is recommended as primarytreatment for inflow arterial stenosis of anyvascular access

Surgical proximal relocation of the vascular accessanastomosis should be considered in juxta-anastomotic stenosis in the forearm

Endovascular treatment with stent grafts should beconsidered for the treatment of cephalic archstenosis

Treatment of central vein

stenosis

The preferred treatment for central vein stenosis is PTA.

Stent placement should be considered in the following situations:

Acute elastic recoil of the vein (>50% stenosis) after angioplastyThe stenosis recurs within a 3-month period.

If symptomatic central venous obstruction issuspected, angiography of the access and complete venous outflow tract should be performed

Treatment should be performed by percutaneous intervention

The use of stent grafts may be considered for thetreatment of central vein stenosis

Stents or repeat balloon angioplasty should beconsidered if there is significant elastic recoil of thecentral vein after balloon angioplasty or if thestenosis recurs within 3 months

Vascular access-clinical practice guidelinesThrombosis & Stenosis

Primary patency

One-year patency

Stent graft vs AngioplastyWhat is new, in the new ESVS vascular access-clinical practice guidelines?

journal of surgical research j u n e 2 0 1 8 ( 2 2 6 ) 8 2e8 8


Access-induced

ischaemia

Patients with an AVF should be assessed on a regular basis for possible ischemia

Patients with new findings of ischemia should bereferred to a vascular access surgeon emergentlyIntervention on a fistula should be performedfor the presence of Ischemia in the access arm

Access-induced ischaemia should be detected byclinical investigation and the cause should beidentified by both non-invasive imaging methodsand angiography

Enhancement of arterial inflow, access flow reduction and/or distal revascularizationprocedures are the therapeutic options. Whenthe above methods fail, access ligation should beconsidered

In patients with symptomatic vascular access induced extremity ischaemia with arterial inflowstenosis balloon angioplasty should be considered

Access aneurysm

Intervention on a fistula should be performedfor the presence of aneurysm formation in a primary fistula. Postaneurysmal stenosis that drives aneurysm also should be corrected.The aneurysmal segment should not be cannulated

Not emphasized Surgical revision of vascular access aneurysms isrecommended if cannulation sites and access diameter can be preserved

Surgical revision of pseudoaneurysms in arteriovenous grafts is recommended when theaneurysm: limits the availability of cannulationsites or is associated with pain, poor scar formation, spontaneous bleeding and rapid expansion

Treatment of infected AVF

Infections of primary AVFs should be treated as subacute bacterial endocarditis with 6 weeks of antibiotic therapy. Fistula surgical excision should be performed in cases of septic emboli

Infection of autogenous AV fistulae without fever or bacteraemia should be treated by appropriate antibiotics for at least 2 weeks

Excision of the fistula is required in case of infected thrombi and/or septic emboli

All vascular access late infections should be treatedwith antibiotics to cover both gram positive andgram negative organisms for 6 weeks

Vascular access-clinical practice guidelinesIschaemia/Aneurysm/Infection

Vascular access induced limb ischaemiaTreatment options

DRIL PAVADRAL

Banding RUDI PRAL


Topic KDOQI European(ERA/EDTA) New European (ESVS)

Catheter placement

Avoid if possible

Ultrasound should be used in the placement of catheters.

The position of the tip of any central catheter should be verified radiologically

Central venous catheters should be inserted as a last resort in patients without a permanent access and the need for acute haemodialysis

The percutaneous route should be used for both acute and chronic catheter insertion. Insertion should be guided by ultrasound

A plain X-Ray (chest or abdomen) should be performed before use to locate catheter and detect any complication

Individuals should not undergo the insertion of a high risk complex haemodialysis line without serious consideration of either the placement of a peritoneal dialysis catheter or a tertiary vascularaccess

Catheter type

Short-term catheters should be used for acute dialysis and for a limited duration in hospitalized patients. Noncuffed femoral catheters should be used in bed-bound patients only

Long-term catheters or dialysis port catheter systems should be used in conjunction with a plan for permanent access

Non-tunnelled catheters should only be used in emergency situations and should be exchanged as soon as possible for tunnelled catheters

Not emphasized

Catheter location

The preferred insertion site for tunneled cuffed venous dialysis catheters or port catheter systems is the right internal jugular vein

The right internal jugular vein is the preferred location for insertion

Not emphasized

Vascular access-clinical practice guidelinesCentral Venous Catheter

Exotic vascular access

Ipsilateral thorax loop Necklace AVG

Axillo-iliac/fem/pop AVG

Arterial-arterial chest wallloop AVG


Topic KDOQI European (EDTA/ERA) New European (ESVS)

Neuropathy

Not emphasized Not emphasized Acute ischaemic neuropathy should be treated byimmediate vascular access ligation to preventfurther neurological deficit

VA after renalTx

Not emphasized Not emphasized Routine closure of a functioning vascular access after successful kidney transplantation is notrecommended

Vascular access closure should be considered in patients with refractory heart failure aftertransplantation

Exhaustedupper limb

access

Not emphasized Not emphasized When standard upper limb vascular access sites have been exhausted, complex access procedures should be considered according to the availability of suitable vessels

Vascular access-clinical practice guidelinesMiscellanous issues

Summary


▪ Set of 9 chapters with 78 recommendations

▪ Low evidence because of few randomised studies

▪ Strategy for VA comparable to other guidelines: 1: AVF; 2: AVG; 3: CVC

▪ No separate strategy for subgroups (elderly; diabetics; bridging to Tx/PD)

▪ Little attention for CVC placement and complication treatment

▪ Tertiary/exotic access well adressed

Invitation to

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Documents

What is new, in the new ESVS vascular access- clinical ......Topic KDOQI European (ERA/EDTA) New European (ESVS) Access-induced ischaemia Patients with an AVF should be assessed on