The Good Old Days of The Good Old Days of Dialysis Access SurgeryDialysis Access Surgery

Eric D. Ladenheim MDEric D. Ladenheim MD

Support gratefully acknowledged Support gratefully acknowledged from from

David Kennedy David Kennedy

W. L. Gore. & Associates, IncW. L. Gore. & Associates, Inc

Overview of talkOverview of talk

There are a lot more AV Fistulas than in There are a lot more AV Fistulas than in the good old days and more are coming.the good old days and more are coming.

Some AV Fistulas and Grafts have weird Some AV Fistulas and Grafts have weird anatomy.anatomy.

The Dialysis Access Surgeon can help The Dialysis Access Surgeon can help make cannulation much easier for you make cannulation much easier for you and your patient.and your patient.

The Good Old DaysThe Good Old Days Ladenheim 1995 - 1998 Ladenheim 1995 - 1998

How Did the USA Compare to How Did the USA Compare to the Rest of the World Prior to the Rest of the World Prior to

2003?2003?Prevalent Vascular Access Percent of Use by

Country: 1996 to 2001 (DOPPS)

0102030405060708090

100

Japan Italy Germany Spain France UK USA

AVF AVG Catheter

The Good Old DaysThe Good Old Days Ladenheim 1995 - 1998 Ladenheim 1995 - 1998

The Good Old DaysThe Good Old Days Ladenheim 1995 - 1998 Ladenheim 1995 - 1998

The Good Old DaysThe Good Old Days Ladenheim 1995 - 1998 Ladenheim 1995 - 1998

The Good Old DaysThe Good Old Days Ladenheim 1995 - 1998 Ladenheim 1995 - 1998

Secondary patency of AVG higher than AVF out to 900 days!

Why is the AVF rate low if it is Why is the AVF rate low if it is the “gold standard”?the “gold standard”?

50% of patients start dialysis emergently, 50% of patients start dialysis emergently, thus catheters are inserted for a quick thus catheters are inserted for a quick vascular access to initiate hemodialysisvascular access to initiate hemodialysis

Patients may resist changing to an AVF Patients may resist changing to an AVF due to fear of needlesdue to fear of needles

Reimbursement for an AV graft is higherReimbursement for an AV graft is higher

AV Grafts can be used sooner than an AV AV Grafts can be used sooner than an AV fistulafistula

Madness and FollyMadness and FollyLadenheim 1999 – 2001 Ladenheim 1999 – 2001

Madness and FollyMadness and FollyLadenheim 1999 – 2001Ladenheim 1999 – 2001

Where we were in 2003?Where we were in 2003?

0

5

10

15

20

25

30

35

40

45

50

U.S. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

33 % Prevalent AVF Northern Cal Region 17

Have we made any progress?Have we made any progress?

Source: March 2006 Network Provider Fistula First Reports

0

10

20

30

40

50

60

70

US 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Region 17 -- Northern California 46.3%

End Stage Renal Disease Network Regional MapEnd Stage Renal Disease Network Regional Map

Prevalent AVF Percentage Rates in USPrevalent AVF Percentage Rates in US

38.1%

48%44.2%

46.3%

58.5% 37.6%

40.7%38.8%

36.3%

34.6%

41.5%

37.5%

47.5%

48.9%

39.5%

35%

40.4%

Date Source: FF Dash Board100% of facilities may not of reported in each Network

Rates across USA & PossessionsRates across USA & PossessionsUS U

S Rate =

Central Valley trails region 17 – but at least we’re better than Sacramento

New and Improved Dr. Ladenheim New and Improved Dr. Ladenheim 2004 to 2007 2004 to 2007

New and Improved Dr. Ladenheim New and Improved Dr. Ladenheim 2004 to 20072004 to 2007

New and Improved Dr. Ladenheim New and Improved Dr. Ladenheim 2004 to 20072004 to 2007

Overview of talkOverview of talk

There are a lot more AV Fistulas than in There are a lot more AV Fistulas than in the good old days and more are coming.the good old days and more are coming.

Some AV Fistulas and Grafts have weird Some AV Fistulas and Grafts have weird anatomy.anatomy.

The Dialysis Access Surgeon can help The Dialysis Access Surgeon can help make cannulation much easier for you make cannulation much easier for you and your patient.and your patient.

Drawing courtsey of James F. Whiting, MDDrawing courtsey of James F. Whiting, MD 2222

Sites for Native FistulasSites for Native Fistulas

(Very Much)

Collaborative Care of Vascular Collaborative Care of Vascular AccessAccess

Surgeons have a role as vascular access Surgeons have a role as vascular access advocates through:advocates through: diagramming new accesses & labeling arterial limbdiagramming new accesses & labeling arterial limb communicating specific access orders directly to communicating specific access orders directly to

the nursesthe nurses visiting the dialysis units to do patient & staff visiting the dialysis units to do patient & staff

education and to familiarize staff c surgeon’s point education and to familiarize staff c surgeon’s point of viewof view

be readily accessible for consultationbe readily accessible for consultation

Surgeon’s Surgeon’s Role: Role:

Diagramming Diagramming accesses accesses

and marking and marking blood flow blood flow directiondirection

Available for ConsultationAvailable for Consultation

Failure of fistulas to matureFailure of fistulas to mature High negative pressuresHigh negative pressures Difficult cannulation situationDifficult cannulation situation Re-Mapping of FistulasRe-Mapping of Fistulas Ligation of parasitic veinsLigation of parasitic veins Monitoring of aneurysms and pseudoaneurysmsMonitoring of aneurysms and pseudoaneurysms Dealing with hematomasDealing with hematomas Evaluation of swollen extremityEvaluation of swollen extremity Poor Blood flowPoor Blood flow Poor dialysis adequacyPoor dialysis adequacy Surgical Follow upSurgical Follow up after graft thombosisafter graft thombosis