mainsat 14 miller balloon assisted angioplasty in avf maturation … · 2018. 4. 1. · 2009...

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Gregg A Miller, MD

Balloon Assisted Angioplasty in AVF Maturation:

CHIEF MEDICAL OFFICER

Fresenius Vascular Care

ASSISTANT CLINICAL PROFESSOR

Columbia University Physicians & Surgeons

DISCLOSURE

Gregg A Miller, MDChief Medical OfficerFresenius Vascular Care

I have no financial relationships to disclose.

www.GreggMillerMD.com

2009 Medicare $491 billion• 3.1% from 2008

2009 TOTAL MEDICARE COSTS

ESRD (5.9%)• $29 billion• 11%

non-ESRD (94.1%)

US Renal Data System: USRDS 2009 Annual Data Report. Bethesda, MD: National Institute of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2009

ANNUAL COST PER PATIENT

Based on 2007 ESRD data:

• $75,344 ($6278.66/mo) for Catheter

• $72,729 ($6060.75/mo) for AVG

• $55,112 ($4592.66/mo) for AVF

Miller GA et al: Percutaneous salvage of thrombosed immature arteriovenousfistulas. Semin Dial. 2011;24(1): 107-114

AVF v AVG

Lee T, et al: Comparison of survival of upper arm arteriovenous fistulas and grafts after failed forearm fistula. J Am Soc Nephrol. 2007;18(6):1936-41

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AVF Creation

AVF SUCCESS RATES

Unassisted Maturation

(40%)

Assisted Maturation;Requires Intervention

(60%)

Dember LM et al: Effect of clopidogrel on early failure of arteriovenous fistulas for hemodialysis: a randomized controlled trial. JAMA. 2008;299(18):2164-2171

Assisted Maturation

of AVF

AVF COMPARISONS

Mature AVF (unassisted)

Catheter

AVG

Peritoneal Dialysis

VS

FISTULA : PRO vs CON

Less cost PPPY -

Low infection rate -

- time to reach clinical success results

in prolonged catheter time

- Variable depth � More infiltrations

PRO vs CONUNASSISTED Maturation vs AVG

FISTULA MATURATION: PRO vs CON

AVF prevalence -

Less cost PPPY -

Low infection rate -

- time to reach clinical success results

in prolonged catheter time

- Variable depth � more infiltrations

- Requires multiple visits

- More procedures / PPY

- adv procedure skill & equip

PRO vs CONAssisted Maturation vs AVG

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TECHNIQUES

1) Flow Rerouting with Elimination of Competing Branch Veins

2) Staged Sequential Dilation

3) Long Length Balloon PTA

4) Limited Controlled Extravasation

Directional Guidance Rotate Guiding Catheter

Step 1: Find the Anastamosis

THROMBECTOMY MATURATION

Wire Guided Selective Catheterization

Step 2: Wire Guided Flow Re-routing

Demonstrate Basilic Vein Pathway

using 0.018 Guiding Catheter


Find Point of Greatest Stenosis

Step 3: Confirm Basilic Outflow Vein

Confirm Lumen


Step 4: Dilate in 1mm Increments until 6mm using Long Length Balloons


Step 5: Retrograde Access Using Balloon Puncture Technique

Dilate Inflow Stenosis Fully Efface all Stenoses & Restore Flow


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Step 6: Restore Flow / Troubleshoot

Forearm Flow-

Check for Perforations

Upper Arm Flow-

Check for Unimpeded Drainage


Step 7: Eliminate Problematic Collateral Veins

Antegrade

Collaterals

Retrograde

Collaterals


Step 8: Dilate Using Inflow Control

• Manual Pressure at anastamosis

• Protect torn distal vein segments

• Avoid exposing injured distal segments to high arterial pressure


Step 9: Final Inspection


Second Ballooning

BEFORE AFTER


Follow-Up at Two Weeks


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Follow-Up at Four Weeks


Aggressive Approach to Salvage Non-Maturing AVF: A Retrospective Study with F/U (n=122)

All unusable AVFs underwent salvage procedures

BAM on AVF DIAMETER

Miller GA et al: Aggressive approach to salvage non-maturing arteriovenous fistulae: a retrospective study with follow-up. J Vasc Access. 2009;10:183-191

% PATENT

Aggressive Approach to Salvage Non-Maturing AVF: A Retrospective Study with F/U (n=122)

Ave Access intvnt/yr= 1.5

Miller GA et al: Aggressive approach to salvage non-maturing arteriovenous fistulae: a retrospective study with follow-up. J Vasc Access. 2009;10:183-191

SECONDARY PATENCY

Kaplan-Meier Survival Analysis (n=122)

(mos)

INTERVENTIONS TO MATURATE

Lee T, et al: Decreased cumulative access survival in arteriovenous fistulas requiring interventions to promote maturation. Clin J Am Soc Nephrol. 2011;6(3):575-81

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VASCULAR REMODELING v VESSEL WALL THICKENING

Lee T, Roy-Chaudhury P: Advances and new frontiers in the pathophysiology of venous neointimal hyperplasia and dialysis access stenosis. Chronic Kidney Dis. 200;16(5):329-38

VASCULAR REMODELING v VESSEL WALL THICKENING

Lee T, Roy-Chaudhury P: Advances and new frontiers in the pathophysiology of venous neointimal hyperplasia and dialysis access stenosis. Chronic Kidney Dis. 200;16(5):329-38

HOW DO YOU PREDICT?

HOW DO YOU PREDICT?

Blood PressureTissue Integrity

First Failure Predicts Subsequent Failure

RADIAL ARTERY ANGIOPLASTY

Turmel-Rodrigues L et al: Percutaneous dilation of the radial artery in nonmaturing autogenousradial-cephalic fistulas for haemodialysis. Nephrol Dial Transplant2009; 24(12): 3782-3788

PREEMPTIVE PTA

Preemptive PTA allows for suboptimal veins

De Marco Garcia LP et al: Primary balloon angioplasty plus balloon agioplasty maturation to upgrade small-caliber veins (

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SALVAGE FROM SALVAGE PROCEDURE

Table 3: Follow-up Stats for 108 Matured Fistulas

Miller GA et al: Percutaneous salvage of thrombosed immature arteriovenousfistulas. Semin Dial. 2011;24(1): 107-114

IMMATURE FISTULA INTERVENTIONS

Miller GA et al: Percutaneous salvage of thrombosed immature arteriovenousfistulas. Semin Dial. 2011;24(1): 107-

114

Miller GA et al: Aggressive approach to salvage non-maturing arteriovenous fistulae: a retrospective study with follow-up. J VascAccess. 2009;10:183-191

AVF

AVF SUCCESS RATES

Success (40%)

Failure (60%)

BAM (93%)

New Access (7%)

2.78 intvnt PPPY

0.06-0.57 intvnt PPPY

0-4.5% infections/yr

0.52% infections/yr

AVF/AVG COST COMPARISON

Success (40%)

Failure (60%)

2.78 intvnt PPPY

AVG

AVF

1.8-5.3 intvnt PPPY$72,729/yr

$55,112/yr

0.06-0.57 intvnt PPPY

0-4.5% infections/yr

0.52% infections/yr

6-22% infections/yr

+$5,487 (maintain)

=$60,599/yr

CONCLUSIONS

Though immature AVF requires more skill, initial procedures, and time….

•Less infections

•Fewer interventions

•Costs less overall

Assisted Maturation AVF AVG>www.GreggMillerMD.com

mainsat 14 miller balloon assisted angioplasty in avf maturation … · 2018. 4. 1. · 2009...

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