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Vascular Access creation in the USA surgical perspective
Surendra Shenoy M.D., Ph.D.
Section of TransplantationDepartment of Surgery
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DisclosuresNo specific disclosures pertaining to
the topic of presentation
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50thAnniverseryofInternal (access) shunts
Brescia MJ, Cimino JE, Appel K , Hrwich BJ NEJY;1966:1089
Cimino Appel Brescia
Cimino Appel Brescia
Brescia Cimino AppelXXXXXXXXX
Vascular Access in USSurgical perspective….. Background
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Vascular Access in USSurgical perspective
Health care changes in US: Impact on VA
Social Security Amendments – 1972All persons with ESRD eligible for medicare
Assured reimbursement
Improved access to healthcare
Physician’s Behavioral change
USRDS ADR Ch XII 1994
Patient profile: elderly, diabetics, ↑ co morbidities
Increased experience better care and longevity
Beneficiaries 10,000 (1970) to >150,000 (1990)
Background
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Background
• Fistulae better than shunts• Need for anatomic suitability• Maturation period• Uncertainty of success
Vascular Access in USSurgical perspective….
Problems with vascular access
AVGBiologic
Xenografts Allograft
Cross linkedCross link
Synthetic
1978 - Human Umbilical vein(Biograft ®, Meadox Meds)- Saphenous vein
1972- Bovine carotid artery(Artegraft ®, Artegraft Inc)
Non cross linkednon antigenic Cryopreserved
(1985) antigenic
Non cross linked
1976
- ePTFE
AVFMultitudes of sites with very little technical changes Snuff box,high & low wrist fistula, brachiocephalic, Gracz AVF, basilicatransposition UA, basilic transposition FA
No attention paid to cause of failure – no need due to short longevity
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Background
Goodkin DA et.al. JASN 2003; 14: 3270
NKF-KDOQI (1995)
‘Fistula First’ (2003)
Vascular Access in USSurgical perspective….
Access population differences Access modality differences Outcome differences
US ESRD population (200,000) ~ 80% AVGJapan ESRD (175,00) ~ 85% AVFEuropean ESRD (30,000) ~ 80% AVF
Schena FP Kidney Int 2000; 57: S39-45
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Increaseddialysis dose
Decreased BP Phos control
Decreased LVH Better nutritionImproved QOL
Williams AW. AJKD 2004;43:90 Kliger AS. CJASN 2009;4:S121
Quality of dialysis depends onfunctioning of vascular access
RAS inhibitors, statins, BP control, Phos control, fluid control etc.
AVG, Catheters and AVF
Strategies to improve ESRD mortality(2000-present)
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Vascular access practice patternsAccess performed by well-trained surgeonsSurgeons trained in graft eraMinimal experience in AVFAccess = joining a vein/graft to arteryHigh rates of primary failure TDC prevalence
Dember LM et.al. JAMA 2008;299:2164-71
Origin and proliferation of image guidedprocedures and devices and catheter industry
Lacson E, et.al. AJKD 2007; 50:379-95
Adaptation of medical communityto changing practice pattern
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Individual dataAVF 79%
AVG 21%
Functional AVF maturation 81.7%
Committed to catheter 3.5%
AVF maturation (ITT) 72%
1 yr. Primary patency 42.5%
1 yr. Secondary patency 81.8 %
Median (range 1.2 - 97.7 mon) followup 36.1 mon
AVF procedures per functional year 0.68
Patient outcome >85% AVF
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VA creation: Changing outcome
Richardson AI et.al. JVA 2009; 10: 199-02 Dember LM et.al. JAMA 2008;299:2164-71Jennings WC. Arc Surg 2006; 141:27-32 Lucas J. J Vasc Surg 2016;
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VA surgical practice patternsLarge Academic Medical center
~ 300 cases in 1 year by 8 surgeons 2 Surgeons performed >60% of procedures These surgeons performed >80% AVF One recent trainee also performed >80% AVF Other surgeons performed AVF ~ 50% patients
Patterns reflect a changing practicepatterns showing improvement in training
and importance of access championsVachharajani N,et.al. J Vasc Surg 2015: s1-s4
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17%
65%
20%
AVF
Catheter
80%
USRDS 2015
VA patterns in incident patientsCMS 2728 & crown web data 2013
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Vascular access surgical training
Eidt JF. JVS 2011; 53: 1130-40
Vascular Board certification data300% increase in AVF (5 in 2003 to 18)
VA is considered a resident case19 residents graduated between 2012 -2014
Required vascular cases 44Average AVF/AVG(range 11-73) 33Revisions (range 1-27) 11Trainees interested in VA 62
Current surgical trainingprovides ample opportunity
Vachharajani N,et.al. J Vasc Surg 2015: s1-s4
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What are some issues?Difficulty to make AVA attractive
High rates of failure
Lack of scientific understanding
Lack of innovative research
Multidisciplinary nature of the practice
Fragmentation of careLack of advocacy
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Inflow
Central outflow
PeripheralOutflow
NAS(Needle access
Segment)
Stenosis is the cause for majority of access circuit failure
Capacity of the pumpdiameter, stiffness & length
of the tubesdetermines the flow
Physiology: AVA maturation & failure
AVG is NAS of the circuit
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Where we are now?
Growing patient population will propelchanges in the field
USRDS 2015
~ 117,000 patients started dialysis in 2012
Total ESRD population ~661,648Hemodialysis (91%) ~421,000Peritoneal Dialysis (9%) ~ 45,000Post transplant ~ 193,000
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SummarySurgical problems associated with
vascular access were part of the evolutionof the speciality.
The current eduction system is robustenough to adjust the need of the changing
practice patterns.There is a need for better understandingand research in the field to improve the
current outcomeIncreasing prevalence of ESRD will
continue to fuel the progress andinnovation
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Vascular Access creation in the USA surgical perspective
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