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
3 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
4 LINC 2021 | AV Symposium | 500568 | 01/2021
Dysfunctional AV Access
▪Stenosis
▪Thrombosis
▪Aneurysm
▪Infection
Image courtesy Tobias Steinke, MD
5 LINC 2021 | AV Symposium | 500568 | 01/2021
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.
6 LINC 2021 | AV Symposium | 500568 | 01/2021
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.
7 LINC 2021 | AV Symposium | 500568 | 01/2021
AV Access: Infections
Pus
Skin Necrosis
Pseudoaneurysm
Image courtesy Tobias Steinke, MD
8 LINC 2021 | AV Symposium | 500568 | 01/2021
AV Access: Infections
PTFE graft lesion from
repeated cannulation
in the same area
Pseudoaneurysm
Images courtesy Tobias Steinke, MD
9 LINC 2021 | AV Symposium | 500568 | 01/2021
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.
10 LINC 2021 | AV Symposium | 500568 | 01/2021
Dysfunctional AV Access
▪Stenosis
▪Thrombosis
▪Aneurysm
▪Infection
Image courtesy Tobias Steinke, MD
11 LINC 2021 | AV Symposium | 500568 | 01/2021
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
12 LINC 2021 | AV Symposium | 500568 | 01/2021
AV Access: Aneurysms
Images courtesy Tobias Steinke, MD
Aneurysm of a brachio-basilic AVF
13 LINC 2021 | AV Symposium | 500568 | 01/2021
AV Access: Aneurysms
Exposure and resection
of the aneurysm End to end anastomsisImage courtesy Tobias Steinke, MD
14 LINC 2021 | AV Symposium | 500568 | 01/2021
AV Access: Aneurysms
Aneurysm of a brachio-cephalic AVF
Images courtesy Tobias Steinke, MD
15 LINC 2021 | AV Symposium | 500568 | 01/2021
AV Access: Aneurysms
Images courtesy Tobias Steinke, MD
There is no endovascular option
…
16 LINC 2021 | AV Symposium | 500568 | 01/2021
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.
17 LINC 2021 | AV Symposium | 500568 | 01/2021
Dysfunctional AV Access
▪Stenosis
▪Thrombosis
▪Aneurysm
▪Infection
Images courtesy Tobias Steinke, MD
cephalic archcentral venous
stenosis
venous
anastomosis (AVG)
venous outflow juxta-anastomotic
18 LINC 2021 | AV Symposium | 500568 | 01/2021
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%
19 LINC 2021 | AV Symposium | 500568 | 01/2021
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.
20 LINC 2021 | AV Symposium | 500568 | 01/2021
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.
21 LINC 2021 | AV Symposium | 500568 | 01/2021
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
23 LINC 2021 | AV Symposium | 500568 | 01/2021
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)
24 LINC 2021 | AV Symposium | 500568 | 01/2021
AV Access Stenoses: Bare Metal Stents
Neuen BL et al. Int J Vasc Med 2015;2015.
25 LINC 2021 | AV Symposium | 500568 | 01/2021
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.
26 LINC 2021 | AV Symposium | 500568 | 01/2021
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 Stent
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.
27 LINC 2021 | AV Symposium | 500568 | 01/2021
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 Stent
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.
28 LINC 2021 | AV Symposium | 500568 | 01/2021
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.
29 LINC 2021 | AV Symposium | 500568 | 01/2021
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
30 LINC 2021 | AV Symposium | 500568 | 01/2021
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 Stent
Juxta-Anastomotic
(Forearm)
Surgical proximal relocation of the vascular access
anastomosis should be considered in juxta-anastomotic
stenosis in the forearm
IIa C DCB
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.
31 LINC 2021 | AV Symposium | 500568 | 01/2021
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 Stent
Juxta-Anastomotic
(Forearm)
Surgical proximal relocation of the vascular access
anastomosis should be considered in juxta-anastomotic
stenosis in the forearm
IIa C DCB
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.
32 LINC 2021 | AV Symposium | 500568 | 01/2021
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 Stent
Juxta-Anastomotic
(Forearm)
Surgical proximal relocation of the vascular access
anastomosis should be considered in juxta-anastomotic
stenosis in the forearm
IIa C DCB
Venous OutflowBalloon angioplasty is recommended for the treatment of
venous outflow stenosisI C DCB
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.
33 LINC 2021 | AV Symposium | 500568 | 01/2021
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 Stent
Juxta-Anastomotic
(Forearm)
Surgical proximal relocation of the vascular access
anastomosis should be considered in juxta-anastomotic
stenosis in the forearm
IIa C DCB
Venous OutflowBalloon angioplasty is recommended for the treatment of
venous outflow stenosisI C DCB
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.
34 LINC 2021 | AV Symposium | 500568 | 01/2021
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.
35 LINC 2021 | AV Symposium | 500568 | 01/2021
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
36 LINC 2021 | AV Symposium | 500568 | 01/2021
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 Stent
Juxta-Anastomotic
(Forearm)
Surgical proximal relocation of the vascular access
anastomosis should be considered in juxta-anastomotic
stenosis in the forearm
IIa C DCB
Venous OutflowBalloon angioplasty is recommended for the treatment of
venous outflow stenosisI C DCB
Cephalic ArchEndovascular treatment with stent grafts should be
considered for the treatment of cephalic arch stenosisIIa B DCB
Schmidli J, Widmer MK, Basile C, et al. Eur J Vasc Endovasc Surg 2018;55:757-818.
Conclusion
37 LINC 2021 | AV Symposium | 500568 | 01/2021
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
38 LINC 2021 | AV Symposium | 500568 | 01/2021
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
39 LINC 2021 | AV Symposium | 500568 | 01/2021
Ultrasound-guided Retrograde Puncture:
Images Courtesy Tobias Steinke, MD
LINC 2021 | AV Symposium | 500568 | 01/202140
Diagnostic Angiography:
Images Courtesy Tobias Steinke, MD
LINC 2021 | AV Symposium | 500568 | 01/202141
POBA / HP:
POBA, 6/40
Images Courtesy Tobias Steinke, MD
LINC 2021 | AV Symposium | 500568 | 01/202142
POBA / HP / Full Inflation:
POBA, 6/40
Images Courtesy Tobias Steinke, MD
LINC 2021 | AV Symposium | 500568 | 01/202143
Check Result of HP- POBA:Before PTA
Images Courtesy Tobias Steinke, MD
LINC 2021 | AV Symposium | 500568 | 01/202144
DCB:
Choose a longer DCB!
Cover POBA treatment area at least
completely
POBA, 6/40
DCB, 7/60
Images Courtesy Tobias Steinke, MD
LINC 2021 | AV Symposium | 500568 | 01/202145
Retrograde Angio Post-DCB:Before
intervention
Image after
treatment
Images Courtesy Tobias Steinke, MD
LINC 2021 | AV Symposium | 500568 | 01/202146
Images Before and After Intervention:
Before intervention Image after treatmentImages Courtesy Tobias Steinke, MD
LINC 2021 | AV Symposium | 500568 | 01/202147