JET 2017February 18th, 2017 13:20~14:50
Garden City Shinagawa The 4th hall (Anemone)
Maintaining 3 Month Blood Flow Strategy
Ikeda Vascular Access Dialysis and Internal Medicine Clinic
Kiyoshi Ikeda M.D.
Today Topics
#1 VAIVT Results
#2 Expansion Technique Examination : Animal model
#3 DW Consideration
#4 Others
Fig.1 : AVF Patency rate 2003-2010
(%)
0
10
20
30
40
50
60
70
80
90
100
0 200 400 600 800 1000 1200
Patency ratio
Patency period
(%)
(days)
Ave. atm Ave. balloon size
A 6.84±2.11 4.62±0.68
B 7.65±3.06 5.18±0.72
C 9.09±9.92 5.31±5.37
〔mean±SD〕
―A group:NSE (n: 63)―B group:Angio Sculpt (n: 45)―C group:DORADO (n:202)
A vs B (n.s.)A vs C (n.s.)B vs C (p<0.01)
Fig.2 : Comparison of Patency period
0
20
40
60
80
100
0 200 400 600 800 1000
After 2012 APRIL (140 cases)
Before 2012 APRIL (240 cases)
(Days)
(%)
※
※: LOGRANK P<0.001
(Kaplan-Meier method)
No.9Ikeda Vascular Access/Dialysis/Internal Medicine Clinic no.9
Fig.3 : Primary Patency of VAIVT in AVF Cases
0
20
40
60
80
100
0 200 400 600 800 1000
After 2012 APRIL (140 cases)
Before 2012 APRIL (240 cases)
※: LOGRANK P<0.05
※
(Days)
(Kaplan-Meier method)
(%)
No.10Ikeda Vascular Access/Dialysis/Internal Medicine Clinic no.10
Fig.4 : Secondary Patency of VAIVT in AVF Cases
Period : 1/1/2016 - 12/31/2016
VA trouble539
PTA : 380 Surgery : 159
AVF : 294 AVG : 86
PTA 20 (52.6%)
Thrombus + PTA18 (47.4%)
Obstruction : 38
PTA 6 (37.5%)
Thrombus + PTA10 (62.5%)
Obstruction : 16
Cuff type catheterization5 cases (13.2%)
Thrombus removal + reconstruction7 cases (18.4%)
Reconstruction 10 cases (26.3%)Thrombus removal 7 cases (18.4%)
(the following : hybrid surgery)Thrombus removal ⇒ PTA ⇒ reconstruction
1 case (2.6%)Thrombus removal ⇒ reconstruction ⇒ PTA
3 cases (7.9%)
Thrombus removal + PTA 5 cases (13.2%)
Obstruction : 38
70.5% 29.5%
77.4% 22.6%23.9%
18.6%12.9%
Fig.5 : Breakdown of access trouble patients treated
Fig.6 :Area of PTA patients introduced from other medical institutions
Period : 2016.1 - 12
Our clinic patients : 33 people , average : 1.9 times
Our clinic63cases
17%
Other hospital317cases
83%
Fukuoka-city
246cases
78%
Other than Fukuoka-city
49cases15%
Other Prefecture
22cases7%
Table1 : The Ratio of the number of VAIVT required within 3 months
PeriodThe number of
cases
The number of VAIVT within 3 months
(number of medical service fee)
Ratio(%)
AVF
2010/9/1 - 2012/3/31 199 56 28.1
2012/4/1 - 2013/3/31 179 34 19.0
2013/4/1 - 2013/12/31 146 39 26.7
2014/1/1 - 2014/12/31 286 131 45.8
2015/1/1 - 2015/12/31 271 66(36) 24.3(13.3)
2016/1/1 - 2016/12/31 294 60(40) 20.4(13.6)
AVG
2010/9/1 - 2012/3/31 137 44 32.1
2012/4/1 - 2013/3/31 98 16 16.3
2013/4/1 - 2013/12/31 64 20 31.2
2014/1/1 - 2014/12/31 96 48 50.0
2015/1/1 - 2015/12/31 92 12(7) 13.0(7.6)
2016/1/1 - 2016/12/31 86 21(15) 24.4(17.4)
Period : 2010.9-2016.12
Fig.7 : The number of Surgeries and PTA
73
267
315 323
399376 380
27
91
96 98
117118 126
2
14
12 17
1218 33
0
100
200
300
400
500
600
2010/9/1-12/31 2011/1/1-12/31 2012/1/1-12/31 2013/1/1-12/31 2014/1/1-12/31 2015/1/1-12/31 2016/1/1-12/31
PTA (2,133) Surgery (673) Catheter (108)(cases)
Today Topics
#1 VAIVT Results
#2 Expansion Technique Examination : Animal model
#3 DW Consideration
#4 Others
【Subject & Methods】
Experimental model, Japanese white rabbit♂(3-4kg)(n=6)
Ikeda method (n=3), High pressure single extended (n=3)
----------------------------1. Make an arteriovenous anastomosis using side-to-side technique between Right common carotid
artery and Right external jugular vein.
2. After 2 weeks, make a stenosis to the venous heart side using Sugita clip.
3. Using a diameter 3.5mm Sugita clip and then make a stenosis about 65%.
4. After 4 weeks, remove the Sugita clip.
5. High pressure single extended type (20atm 30seconds) using 10mm Conquest balloon. Extended by Ikeda method.
6. After 4 weeks in PTA, terminate for pathological examination
4 weeks
Side-to-side anastomosis to Right common carotid artery and Right external jugular vein
Make an AVF Make a Stenosis
Using 5mm Sugita clipMaking a stenosis about 65%
Remove a clip Terminate
2 weeks
PTA
Extend by 10mm balloon(20atm 30seconds)
4 weeks
Make an AVF
artery
anastomosis vein
Make an arteriovenous anastomosis using side-to-side techniquebetween Right common carotid artery and Right external jugular vein.
After 2 weeks make a AVF
Enlarged anastomosis : diameter 10mm
anastomosis
Make a stenosis using a Sugita clip
make a stenosis about 65%
After 2 weeks, make a stenosis to the venous heart side using Sugita clip.Using a diameter 3.5mm Sugita clip and then make a stenosis about 65%.
Remove Sugita clip after 4 weeks making a stenosis
Using a diameter 3.5mm Sugita clip and then make a stenosis about 65%.After 4 weeks, remove the Sugita clip.
Expand by 10mm balloon
Conquest balloon
High pressure single extended type (20atm 30seconds) using 10mm Conquest balloon. Extended by Ikeda method.
<Ikeda method><High pressure
single expansion>
Fig.8
Make an AVF, put a Sugita clip on the heart V-side for 2 weeks
After 4 weeks, PTA
Terminate after 4 weeks
Fig.9 : Comparison of blood flow
AVF作成前 AVF作成後 2w後狭窄前2w+4w後クリッ
プ解除前2w+4w後拡張後
2w+4w+4w屠
殺時
15-02 41 208 277 139 274 28015-13 32 105 358 510 335 4015-20 40 126 199 182 105 25515-01 37 128 256 256 22515-12 30 98 212 285 685 29015-19 46 115 252 462 314 500
0
100
200
300
400
500
600
700
800
Hig
hLo
w
Blockade perfectly
Before AVFAfter 2 weeks, before stenosisAfter AVF
After 2+4 weeks, before remove a
clip
After 2+4 weeks, before extended
After 2+4+4 weeks, slaughter
High pressure single expansion15-02_9EM×1.25
15-13_9EM×1.25
15-02_9EM×20
15-13_9EM×20
Intimal thickening
High pressure single expansion15-02_9HE×1.25
15-13_9HE×1.25
15-02_9HE×20
15-13_9HE×20
intimal thickening
intimal thickening
invasion of the smooth muscle
intimal thickening
Ikeda method15-01_7EM×1.25
15-12_10EM×1.25
15-01_7EM×20
15-12_10EM×20
Ikeda method15-01_7HE×1.25
15-12_10HE×1.25
15-01_7HE×20
15-12_10HE×20
【Results】
1) One case of occlusion was observed in the Single Expansion group.
2) Evidence of Intimal thickening and invasion of the smooth muscle was present in the Single Expansion group.
3) Ikeda Method group showed a clear difference of intimal thickening compared to Single Expansion group.
4) Even when pressure was increased from 20 to 30 standard atmospheres using the Ikeda Method, membrane damage was minimal.
【 Conclusions】1) In an animal experiment, frequent expansion using low pressure (Ikeda method) and single expansion using high pressure were performed.
2) Remarkable intimal thickening and thrombotic adhesion were observed after four weeks in high pressure single expansion case.
3) Using Ikeda Method, Neither intimal thickening nor invasion of the smooth muscle even with pressurization of 20 standard atmosphere were observed.
Future policy
Pathological results showed that using frequent gradual pressure increase (Ikeda Method) was more effective and less damaging than Single High Pressure Expansion Method. Increase in Patency Period was also a benefit of using Ikeda Method.
Today Topics
#1 VAIVT Results
#2 Expansion Technique Examination : Animal model
#3 DW Consideration
#4 Others
VAIVT:Docter decides devices and therapy’ method
VA management: Periodical check using ultrasound
Strategy to extend patency period
【Background 1】
※Management using ultrasound to evaluate VA condition does not contribute to extend primary patency period.
※ Determining Hemodialysis Patient’s DW in dialysis unit is very important.
【Background 2】
#1 CTR#2 Blood Pressure#3 Measurement of IVC after hemodialysis
#4 BCM examination
DW Determination Factors
BCM is an analysis device using the principle of electric resistance.A faint electric current flows through the body, giving an up-to-date measurement of body water, body fat and muscle mass.
BCM(BodyCompositionMonitor)
BCM : made by Fresenius Medical Care AG & Co. KGaA, Germany
Electric flow varies depending on water amount. ・High fat content (low muscle mass) = high electric resistance・Low fat content (high muscle mass) = low electric resistance
Using BCM analysis we can determine ideal body weight.
<Input of Personal information>1) Height2) Weight3) Age4) Sex
BCM(BodyCompostionMonitor)
【Objects】
Number of Hemodialysis Patients: 110
Period : Jan.2014-Dec.2015
BCM Examination : PTA(-) 261 times vs PTA(+) 139 times
-3
-2
-1
0
1
2
3
A値 B値
mean±SE
PTA(-)(n=261)+0.13Kg
PTA(+)(n=139)-0.96Kg
P=NS
Fig.10 : Comparison of BCM results (DW-Ideal BW)PTA(-) vs PTA(+)
2015;74.2%
2014;39.6%
p:ns
Patency ratio
【Results】
Fig.11 : Primary Patency Period
DAYS
Today Topics
#1 VAIVT Results
#2 Expansion Technique Examination : Animal model
#3 DW Consideration
#4 Othersa) Milking Methodb) Firapy
【Pressure VA Massage(PVM)】
~Points~
PVM is done by pushing blood to stenotic area using both hands.
①One hand stops shunt flow on the down flow side.
②The other hand presses vein from up flow side.
This method stretches stenotic area.
【Results 1】
1.46
0.63
1.16
1.89
0.570.94
0
1
2
3
4
5
6
7
狭窄径(mm) FV(mL/min) RI PI
1.57
0.420.57
2.04
0.33 0.41
0
1
2
3
4
5
6
狭窄径(mm) FV(mL/min) RI PI
490
610
420
480
(+29.5%)
(+24.5%)
(+9.5%)(+19.5%)
(+29.9%)
(+14.3%)
(+21.4%) (+28.1%)
Results after examination.
Case1 Case2
Diameter (mm) Diameter (mm)
Before PVMAfter PVM
Fig.12 : Ultrasound Examination Data
58.6
111
0
20
40
60
80
100
120
VAマッサージ開始前 VAマッサージ開始後
70
124
0
20
40
60
80
100
120
140
VAマッサージ開始前 VAマッサージ開始後
n=6 n=4
Case1 Case2
This method contributed to 3 month rule.
VA massage before the start VA massage after the start VA massage before the start VA massage after the start
【Results 2】Fig.13 : Patency period (days)
What FIRAPY can do for vascular access
Improve AVF Maturation for early use
Increase Blood Flow
Maintain VA Patency
The practice of Far-Infrared Therapy Unit
92% Hemodialysis centers use FIRAPY in Taiwan
>90%
HD centers
equipped with FIRAPY
in Taiwan
The HD situation in Taiwan
• Area: 36,000 square km
• Population: 23 million
• Dialysis Patients: 80,000
• HD centers: 600 1/287
1 -year Survival Curves for Unassisted
Patency of AVF between the two HD Groups
J Am Soc Nephrol. 2007; 18:985-992
Nephrol Dial Transplant 2013 May; 28(5): 1284-93
5-year Survival Curves for Unassisted Patency of AVF between the two HD Groups
Parameter Control GroupFIRAPY
Groupp
No. starting study 73 72 -
Patients with new AVF malfunction (%) 22 (30.1%) 9 (12.5%) <0.01
Patients with thrombosis of AVF 6 (8.2%) 2 (2.8%) 0.15
Patients with intervention of AVF 16 (21.9%) 7 (9.7%) 0.044
Total observations (patients-months) 802.4 812.6 -
New episodes of AVF malfunction during
study30 12 -
Episode of AVF malfunction/patient-months 1/26.7 1/67.7 0.03
Far-infrared Therapy reduce the malfunction of fistula after 1 year treatment
J Am Soc Nephrol. 2007; 18:985-992
#1 Existing devices limit potential for extending patency period.
#2 Existing devices have potential for extending patency period if expansion technique is used.
#3 The accuracy of DW management helps to avoid VA trouble.
#4 ① VA massage is possible on vein close to surface.② There are reports that use of ultraviolet rays on VA is
beneficial.
【 Conclusions】