Présentation PowerPoint

¿Quál es el lugar des los injertos protésicos?
What is the place of AV grafts?
Richard Shoenfeld MD, FSIR, FAHA
SEDAV 2014, Madrid
The Access Center at West Orange
West Orange, New Jersey
USA
November 7, 2014
The Ideal World
ESRD stage IV
Suitable anatomy: usable inflow – outflow, cannulation
area
Successful AVF - below the elbow
No distal ischemia
Normal maturation – « rule of 6’s »
6 weeks to maturity
6-mm deep
≥ 600 ml/sec bloodflow
Reality
Significant co-morbidities (PVD, CHF), poor prognosis
Acute, urgent HD, insufficient/no pre-dialysis planning
Inadequate/end-stage vascular anatomy, obstructing implantable devices
High primary failure rate: 20 – 60%, 1,2 potential protracted TDC use
1. Vazquez MA. Curr Opin Nephrol Hypertens. 2009;18(2):116-121
2. Allon M. Clin J Am Soc Nephrol. 2007;2(4):786-800
Four key considerations in choosing
AV access:
1. Likelihood of early access complications
and primary failure.
2. Likelihood of later access complications,
i.e., stenosis, thrombosis.
3. Catheter-related complications
(bacteremia, CV obstruction).
4. Patient survival.
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Selective use of grafts in high-risk patients
may afford similar cumulative patency with
reduced exposure to the risks associated
with catheters*
*Allon M. Clin J Am Soc Nephrol. 2007;2(4):786-800
Lok C. Clin J Am Soc Nephrol. 8: 810–818, 2013
What additional data may help us choose the most appropriate
access type for each patient?
Association between vascular Access Type and adverse outcomes
Ravani P et al. J Am Soc Nephrol. Feb 28, 2013; 24(3): 465–473.
Quinn R, Ravani P. Nephrol Dial Transplant (2014) 29:727-730
CV caths associated with much higher risk of death,
infection, cardiac events and hospitalization compared
with AVF, AVG. Biofilm colonization, inflammation?
AVGs associated with higher risk of death, sepsis, and
hospitalization compared with AVFs
Ravani P et al. J Am Soc Nephrol. Feb 28, 2013; 24(3): 465–473.
Mortality differences attributable to health status,
access type or selection bias?
Unadjusted model – risk of death (HR):
AVF (1.0) < AVG (1.20) < Catheter + AVF (1.34) < catheter + AVG (1.46) < catheter alone (1.95 )
Meta-analytical RR (USRDS)
AVG vs AVF 1.18
Cath vs AVF 1.53
Model 1: incl. std covariates (co-morbidities, pre-HD Nephr. Care, sociodemographics)
- 23.7% overall HR reduction (all other types of access vs AVF ): AVG (1.22) < cath + AVF (1.27) < cath + AVG (1.38) < Cath alone (1.69)
Model 2: incl. limited functional health status, # hosp days x 2yrs pre-HD
Additional -19.7% overall HR reduction (all other types of access vs AVF): AVG (1.18) < cath + AVF (1.20) < cath + AVG (1.26) < Cath alone 1.54)
Association between access type at HD initiation and
5-year mortality in 117, 277 patients from 2005 - 2007.
% Pts w/Lim. funct. status: AVF, AVG, Cath alone: (10.8%), (18.8%), (25.5%)
Hospital days 2 yrs prior to dialysis: AVF, AVG, cath alone: (5.4), (10), (18)
Grubbs, V, Wasse H et al. Nephrol Dial Transplant (2014) 29: 892–898
Once AV access needs intervention, which does best?
Yan Y, et al. J Vasc Interv Radiol 2013;24
Hemodialysis Reliable Outflow (HeRO) device
Long-term subcutaneous vasc. access device
Direct arterial access in patients with CVOD
Demographics and access history
Katzman H et al. J Vasc Surg Sep 2009; 50(3)
HeRO patency, intervention rates vs literature
3.2*
* Yan Y, et al. J Vasc Interv Radiol 2013;24
Katzman H et al. J Vasc Surg Sep 2009; 50(3)
HeRO – related bacteremia results
Katzman H et al. J Vasc Surg Sep 2009; 50(3)
HeRO conversion for early use
Schuman E. J Vasc Surg Jun 2011; 53(6)
Conclusions - AVGs
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Pts with successful AVFs have better
clinical outcomes.
Earlier elective AVF planning/creation.
Sites inaccessible for AVF creation.
Lower initial failure rate than AVFs.
1° patency < AVFs.
2° patency similar to nAVFs, worse than
tAVfs….more maintenance.
Early-use AVG instead of TDC in
appropriate context
Early-use HeRO device vs TDC in end-stage
CVOD
or
Fistula Group
Fistula first (and early), AVG next;
Catheter(urgent)…. last!