4/25/2009. Other 8% Thrombosis? Stenosis 8% 74% Infection 10%

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1 Hells and Hosannas of Vascular Access Or what to do in some Hellish Vascular Access situations Marc H Glickman MD Eastern Virginia Medical School Sentara Medical Group Norfolk, Virginia, USA Who is the new Access Patient? Elderly patient: Average age : 63yrs Diabetic Nephropathy High BMI Hispanic African American Outline of Talk A. What to do with patients that have recurrent thrombosis B. Dealing with the patient with Central Vein Stenosis C. Graft Infections The non compliant patient Increasingly complex patients with multiple comorbid conditions 1

2 Causes of Graft Failure We know from Huber s analysis, that once a graft thrombosis, the likelihood of further graft thrombosis increases significantly and patency rates of future grafts is decreased significantly This is of major concern, and causes us to think of other options for our patients Infection 10% Stenosis 8% Other 8% Thrombosis 74% Thrombosis at the venous anastomosis is the primary cause of graft failures (typically occurring > 6 months) Hodges et al. Longitudinal comparison of dialysis access methods: Risk factors for failure. J Vascular Surgery 1997, 26(6): What do we know about graft Thrombosis? It s probably more common than we like to talk about. A lot of access patients have subtle alterations in their hemostatic function. The process of dialysis probably induces a chronic inflammatory state increasing the risk of thrombosis. Coagulation Alterations in Patients with Recurrent Access Thrombosis Anticardiolipin antibodies 58% Anti-bovine thrombin 32% Heparin induced antibodies 18% Elevated factor VIII 90% Elevated fibrinogen 62% Elevated C-reactive protein 42% Elevated homocystine 81% Factor V leiden 0% 2

3 Bovine Mesenteric Vein This graft has actually been one of the most studied grafts in access surgery Multiple studies from USA and Europe have demonstrated superior patency rates when compared to eptfe grafts in patients with ESRD with recurrent graft failures Bovine Mesenteric Vein We were part of a multicenter, randomized prospective trial comparing past eptfe grafts to the BMV graft ( Procol ) Procol for Salvage Dialysis Access: Assisted Patency of Procol vs. Last PTFE Clopidogrel Assisted Patency (%) P= Procol PTFE Time (Months) New Data from the DACC study, with reanalysis demonstrates an increase in AVG patency rates in complex patients 3

4 Summary Patients with a early and recurrent graft thrombosis have a high rate of biochemical abnormalities. Factor VIII 90% Homocystine 81% Fibrinogen 62% Anticardiolipin antibodies 58% Biologic conduit appears to function well in this high-risk patient population. Careful use of Clopidogrel and anticoagulant therapy appears to improve graft patency.. Central Vein Stenosis/Occlusion With the Fistula First Initiative, Catheter utilization has increased significantly Central vein problems results in arm swelling, graft thrombosis and the inability to use the ispilateral extremity for access usage Occluded left brachiocephalic and subclavian veins despite central stent. 4

5 18 The Catheter Problem HeRO Vascular Access Device High related bacteremia rates, morbidity, mortality and increased hospital costs > 40% have central venous stenosis AVF Stenosis 27-38% prevalence in HD patients Most = Catheter Dependent Catheter dependency: 58% increase from Occluded SCV Stent L. R. Sprouse, et al. Percutaneous treatment of symptomatic central venous stenosis. J.Vasc.Surg. 39 (3): , MacRae J, Ahmed A, Johnson N, et. al. Central Vein Stenosis: A common Problem in Patients on Hemodialysis. Nephrology. ASAIO Journal 2005;51:77-81 Ramanthan, V., Chiu, E.,Thomas, J., Khan, A., Dolson, G., Darouiche, R. Healthcare Costs Associated with Hemodialysis Catheter-Related Infections: A Single-Center Experience. Infection Control and Hospital Epidemiology (5): pp USRDS CPM Table HeRO Device Overview HeRO Titanium Connector 6mm eptfe Graft Brachial Artery Titanium Connector 5mm Silicone Outflow Catheter Right Atrium 5

6 22 HeRO Vascular Access Device Catheter dependent or approaching dependency Not candidate for upper arm access Failing AVF / AVG Titanium Connector 75 Patients From 9 Sites Female 54.7% Male 45.3% Mean Age 57.8 yrs White 25.3% Black 62.7% Hispanic 8% Native American 2.7% Asian 1.3% Mean BMI 32.8 Diabetes 58.7% Mean Yrs on Dialysis: 4.6 (63pts) Mean HD Catheters/pt: 5.2 (63pts) Mean AVG/ pt: 2.1 (51pts) Mean AVF/ pt: 1.6 (44pts) Occluded SVC Azygous Vein insertion HD method prior to HeRO implant De novo / poor anatomy 2.7% Femoral catheter 14.8% IJ catheter 58.0% SCV catheter 5.4% AVF 4.1% Thigh AVG 1.4% Upper arm AVG 9.5% Femoral catheter & upper arm AVG 1.4% HeRO device & translumbar 2.7% unknown 1.3% Catheter Dependence 79.6% 6

7 Outflow Access Vein for Insertion IJV = 72% SCV = 24.1% Azygous vein = 1.3% Brachial vein = 1.3% Endovascular Techniques Needed Pre- insertion PTA Serial dilation 52.1 % 22.9 % Tunneled Dialysis Catheter Central Venous Stenosis / Fibrin Sheath Basilic vein = 1.3% *Contralateral veins considered R. brachial artery graft to L. IJV outflow catheter Serial dilation & PTA 18.7 % Mean Operative Time: 96 min. Techniques used to assist placement Balloon assist outflow component introduction 44.6% Rewire existing catheter 30.7% Other internal support / lube 14% None 10.7% Internal Support 19 Fr outflow component 6 soft balloon Balloon and its shaft provide extra support Type of Anesthesia General 93.3% Conscious sedation 2.7% Local 2.7% Conscious sedation & local 1.3% 4% Reintervention rate prior to discharge home 2 pts. = Thrombectomy ***1 explant before d/c 1 pt. = HIT (required argatroban) 100% Technical Success Titanium Connector Outflow Outflow Component Component Tip to Right Atrium Graft Component Dialysis Access Brachial Incision 0% Operative Mortality 7

8 Proposed Access Pathway Non Dominant Arm AVF/ Dominant Arm AVF Non Dominant Arm AVG/Dominant Arm AVG HeRO Catheter Thigh AVG Infection in Dialysis Patients 1961: Shriener noted that renal failure patients had a higher rate of infection than the general public He reported a 50% bacteremia rate in patients with ESRD Catheter Dependence Infection in Dialysis patients Dialysis superimposes a new myriad of problems for these patients WBC and complement dysfunction occurs from contact with the dialysis membranes Higher exposure to bacteria and pyrogens from contaminated solutions and unsterile techniques in the dialysis units Infection in Dialysis patients In 2001, the infection rate from bacteremia remained at 50% No significant change in incidence in 40 years Access related infection is the most important cause of loss of vascular access for dialysis 8

9 Infection in Dialysis Patients Dialysis related bloodstream infections are the second leading cause of death in patients undergoing hemodialysis Accounts for 10% of deaths in patients undergoing dialysis Diagnosis of infected Graft Diagnosis is not always clear cut and is often made when everything else is negative Duplex of the graft to visualize perigraft fluid collection has become a hallmark for determining infected AVG Diagnosis of Graft Infection Radio labeled leukocyte scan is also used and is helpful especially in abandoned grafts 95%-100% sensitive 90%-93% 93% specific Clinical Diagnosis of Infected Grafts Draining sinus tract with localized erythema May represent a portion of the graft infected on just a small section Exposed graft By definition is an infected graft that still can be salvaged 9

10 Clinical Diagnosis of Infected Grafts Thrombosed and abandoned grafts pose a continued infection and this may not be apparent by examination Schild reported in a large series a 23% incidence rate of infection in thrombosed and abandoned grafts Nassar also reported a high incidence of infection in abandoned grafts as well Pathogens of Graft Infection Staph aureus is the most common pathogen Studies range from 60%-77% for staph aureus 22% staph epi 23% gram negative organisms MRSA infection continue rise significantly in this patient population Risk factors for Graft Infection Multiple prior graft infection is the leading predictor for another graft infection One graft infection raises the incidence 10 fold for another graft infection Operative infection rate 3-6% in this group of patients Risk of Graft Infection Serum albumin <3.5 high predictor for infection in AVG Presence of Tunnel dialysis catheter at the time of implant Increase infection rate 2 fold 10

11 Risk of Infection Incomplete resection of prior infected grafts results in a 17% incidence of recurrent surgery for total graft excision 50% of all infections develop at prior and recurrent needle cannulation site Outcomes with Infected Grafts Minga and Allon reviewed 90 graft infections in 78 patients over a 4.5 year period of time 8.2 infections per 100 graft years 15% of infections occurred with 1 month of implant 44% occurred with 1-2 month of implant Outcomes of Graft infection 41% of infections occurred > 1 year after implant Average hospitalization 7.5 days 12% of patients developed sever complications 6.4% mortality 12% of patients became catheter dependent for over 1 year Outcomes of Graft Infection During this 4.5 year follow-up, 9.7 access procedures were required for the average patient While patients were catheter dependent,.85 episodes of bacteremia per patients 11

12 Management of Infection Management of Infected Grafts Total Graft Excision Sepsis Duplex exam Calligaro and Doughtery presented an algorithm on management of infected prosthetic AVG from a series of 51 infections in 45 patients Subtotal Graft Excision Partial Graft Excision Management of Infected Grafts Total Graft Excision: Septic &Critically Ill Use tourniquet for forearm excision of graft Subtotal Graft Excision: Stable Patients with incorporated arterial anastomosis Partial Graft Excision-Jump graft when localized infection is present Cull reported success in 17 patients Management of Infected Grafts Brachial Artery Repair Primary repair if possible however gram negative infection without coverage may be dangerous Vein Patch angioplasty if primary repair is not possible Adequate closure is necessary in patients with gram neg infection 12

13 Prosthetic Graft Management Several studies have demonstrated a lower incidence of recurrent graft infection using Bovine Mesenteric Vein instead of eptfe graft when placing a new AVG Prosthetic Graft Management Historically, thigh grafts have a higher rate of infection than grafts placed in the upper extremity, 3 fold increase in infection rate Use of Bovine Mesenteric Vein reduces this incidence to the same rate as graft placement in the upper extremity Conclusion There are potential and certain Hells in Access surgery Knowing new options and new alternatives may allow for success in maintenance of the access with successful outcomes for our patients Thank you mhglickm@sentara.com 13