AV Fistula Creation by a US Interventional Nephrologist

Rick Mishler, MD, FACP Interventional Nephrologist AKDHC Surgery Center Phoenix, AZ

Analysis of Initial Experience

Annual Dialysis Conference San Francisco, CA February 26, 2006

Back Ground
     

US nephrologist currently with 8 years of interventional experience Trained in autologous fistula creation by a US vascular surgeon for several months Setting: ambulatory surgery center that provides comprehensive vascular access care Additional training with a European nephrologist 117 consecutive avf creations in 116 patients as solo operator September 2004-September 2005 2004-

Demographics


64.1 (23-88) years average patient age (2345 (39%) female 61 (52 %) of the patients were diabetic

Patient CKD Stage



71 (61%) - stage 5 43 (37%) - stage 4 2 patients stage 3

Procedure
      

Performed in vascular access ASC OR Versed and fentanyl conscious sedation Oxygen by nasal canula RN administered meds and monitored pt Surgical scrub technician assisted Average procedure length: 74 (46-133) minutes (46Average systemic heparin dose was 3831 units

Locations of the Anastomoses



18% radial artery-cephalic vein anastomosis artery19 left  2 right



82% brachial artery - cephalic, basilic or perforating vein anastomosis

81 left  15 right


Vessel sizes


Measurements from preoperative ultrasound vessel mapping (108/116) Artery: 4.1mm (82% brachial artery) Vein: 3.6 mm

Complications


4 brachial artery avf caused steal syndrome

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


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

US Surveillance
    

6 wks post creation 77/117(66%) obtained 70/77 (91%) maturing 5/77 (6%)thrombosed 2 lost to follow up

    

12 wks post creation 64/117(55%) obtained 54/64 (46%) maturing 7/64 (6%) not mat. 3 (4.6%)thrombosed

Interventions


12 (10%) accesses thrombosed

 

5 underwent endovascular thrombolysis/pta 1 was successful

 

28 (24%) avf required other intervention with pta and/or accessory drainage vein occlusion(6). 2 of these were subsequently abandoned 34/40 (85%) interventions yielded avf that continued to function/mature (Kian et. al., KI, 2006)

Surgical Revisions


1 brachial-cephalic avf was created when the brachialinitial radial-cephalic avf failed radial5 basilic vein avf required transposition and 2 of these have been accomplished 2 juxta-anastomotic segments may require juxtarevision 2 avf may require superficialization

Longitudinal Data
  

Average follow up: 287 (157-516) days (157Mean follow up: 346 days Average to cannulation: 149 (29-427) days (29(CKD + ESRD avf) Mean to cannulation: 228 days (CKD+HD avf)

Current Status of AVF



47% became active

  

HD CKD w/ US maturity Died w/ active avf HD PD CKD

42% are maturing

  

11% failed

Current Status of AVF Detail

   

43 (37%) are in use for dialysis 2 patients died with active avf 9 (8%)CKD but OK to cannulate by US 45 (38%)maturing
21 remain CKD and developing  22 HD ESRD using an alternative access  2 PD ESRD


 

5 (4%) patients died w/ developing access 13 (11%) avf failed and are abandoned

Perspective
6000 5000 4000 Mishler 3000 Konner 2000 1000 0 # of VAP Mishler Konner 185 5072

Conclusions: Conclusions:


Given adequate experience and training in the proper environment, it is possible for a US nephrologist to create av fistulae with satisfactory patent and access outcomes. It seems likely that the results were enhanced given the availability and implementation of ultrasound surveillance and endovascular procedures. This concept requires further validation by other centers.

THANK YOU TO:

Gerald Beathard, MD, PhD Henry Tarlian, MD Klaus Konner, MD Kam Takesian, RN