1. Marko Malovrh Ljubljana Slovenia
What should be the role of nephrologist in the care of vascular access?
Marko Malovrh
Ljubljana
Slovenia

2. ISN CME Course „Nephrology Update 2016“
Disclosure of speaker’s interests
Conflict of Interest
None
Financial Relationships
None

3. Objectives Current situation and trends of VA in the world
Short history about the role of nephrologists
Preoperative period – from the findings of CKD to the decision on the type and construction of vascular access
Surgical construction – when, how and who?
Post-operative surveillance – when, who and how?
Complications
Cannulation of AVF or graft
Conclusions

4. Vascular accesses in prevalent patients
Italy
Germany
France
Spain
Belgium
I = ; II= ; III = (DOPPS); IV (DOPPS)

5. Vascular accesses in prevalent patients
Sweden UK
Japan
ANZ
Canada US
I = ; II= ; III = (DOPPS); IV (DOPPS)

6. Vascular accesses at incident HD patients
Vascular accesses use, by country among incident HD patients (DOPPS data )

7. Nephrologists are traditionally educated:
Kidney physiology and patho-physiology
Management of kidney diseases
Familiar with renal anemia, ostreodystrophy, heart diseases and many others disorders of ESRD
Initiate and supervise dialysis treatment
Care for pts before and after kidney transplantation
Should be also educated to recognize the pivotal role of VA for hemodialysis patients and to be proactive in VA acitvities

8. Nephrologists were involved historically into VA problems in the early years of HD treatment:

9. 1965/66 2004-2008 1970 Dr.Klaus Korner Germany In Italy In India
An upper arm A-V fistula for hemodialysis patients with distal access failures Someya S, Bergan JJ, Kahan BD, Yao ST, Ivanovich P. Trans Am Soci Artif Intern Organs. 1976; 22: Stapler for A-V anastomosis: simplified, immediate vascular access. Ivanovich P. Kahan BD, Someya S, Bergan JJ, et al. Trans Am Soci Artif Intern Organs 1977; 23:
Dr.Klaus Korner Germany
More than 5000 procedures
Many technical inovations
In Italy
In India

10. First AVF construction 7.1.1974 by nephrologist
First Goretex graft: by nephrologist
Dr.Henrik Mulec
Dr.Jože Drinovec

11. NEPHROLOGISTS-SURGEONS OF VA IN UKC LJUBLJANA
dr. Jože Drinovec
dr. Radoslav Kveder
dr. Rafael Ponikvar
dr. Marko Malovrh
dr. Vladimir Premru
dr. Boštjan Kersnič – SB Trbovlje
dr. Alenka Urbančič

12. Prevalent patients in Slovenia
Adapted from: Buturovic-Ponikvar J, et.al. Ther Apher Dial  2016 Jun;20(3):223-8.

13. Incident patients
Adapted from: Buturovic-Ponikvar J, et.al. Ther Apher Dial  2016 Jun;20(3):223-8.

14. Percent catheter use in pts first seeing by nephrologist prior initiating dialysis
Adapted from:Either, et.al. NDT 2008;23:

15. Patient survival in four groups
Lorenz et al. Am J Kidney Dis 2004:43;

16. Nephrologists have to be involved in VA activity at different periods of CKD, HD, CAPD and Tx pts: - Early and late period of CKD, - Pre-dialysis period, - Period before surgery, - Period of VA creation, - Period of VA maturation, - Following of VA function during HD treatment and after tx kidney

17. Role of nephrologist in creation of VA:
To achieve a functional and permanent VA – VA
creation plan is crucial.
Early care by nephrologist-VA surgeon or early referral to VA
surgeon has a clear benefit for incident patient in
achieving a timely initial VA creation so that the VA can be
used at initiation of HD therapy.
Choice of strategy should be guided by assessment of individual’s
rate of CKD progression to avoid excessively early or late referrals.

18. Role of nephrologists in early, late period of CKD and in pre-dialysis period:

19. Physical examination of vessels
CKD patient eGFR
≤ 30 mL/min
Malovrh M. Contrib Nephrol. 2015;184:13-23. No
Yes
Preservation of veins
Education programme of patients, nurses and physicians
Vein preservation:
- educational program for
patients, nurses and physicians
Clinical examination
Physical examination of vessels
Medical history and concomitant diseases:
Age
Gender
Hypertension
Diabetes
Cardiac diseases
Peripheral arteries
diseases
Veins
Arteries
Tourniquet placed:
- Visibility
Continuity
Distension
Side braches
Arm or thoracic
collaterals
- Quality of arterial
pulse
Blood pressure at both
arms
- Allen test
Duplex ultrasound
VEINS
- Internal diameter (>2-2.5 mm)
Internal diameter with inflated cuff – increasing
for ≥ 0.4 mm or > 15% (distensibility) (Figure 3)
- Depth of vein ≤6 mm
- Quality of vein wall – no fibrotic changes
No side branches or ligation them during
surgery
- Changing of Doppler waveform during respiration -
increasing during inspiration (Figure 4)
ARTERIES
Internal diameter (>2-2.5 mm)
Calcification (severe-move towards upper
part of forearm)
- Doppler flow velocity (≥ 25 cm/s)
Resistance index (RI) at reactive hyperemia-
≤ 0.7 or change of HRF to LRF (Figure 5)

20. Preservation of veins:
Do not use veins at the upper arm for blood samples or infusions
Do not use central vein catheters
Excercises for increasing of veins

21. Physical examination of vessels
CKD patient eGFR
≤ 30 mL/min No
Yes
Clinical examination
Vein preservation:
- educational program for
patients, nurses and physicians
Clinical examination
Physical examination of vessels
Medical history and concomitant diseases:
Age
Gender
Hypertension
Diabetes
Cardiac diseases
Peripheral arteries
diseases
Medical history
Age
Gender
Arterial hypertension
Diabetes
Heart diseases
Periheral artery diseases
Veins
Arteries
Tourniquet placed:
- Visibility
Continuity
Distension
Side braches
Arm or thoracic
collaterals
- Quality of arterial
pulse
Blood pressure at both
arms
- Allen test
Duplex ultrasound
VEINS
- Internal diameter (>2-2.5 mm)
Internal diameter with inflated cuff – increasing
for ≥ 0.4 mm or > 15% (distensibility) (Figure 3)
- Depth of vein ≤6 mm
- Quality of vein wall – no fibrotic changes
No side branches or ligation them during
surgery
- Changing of Doppler waveform during respiration -
increasing during inspiration (Figure 4)
ARTERIES
Internal diameter (>2-2.5 mm)
Calcification (severe-move towards upper
part of forearm)
- Doppler flow velocity (≥ 25 cm/s)
Resistance index (RI) at reactive hyperemia-
≤ 0.7 or change of HRF to LRF (Figure 5)

22. Physical examination of veins Physical examination of vessels
CKD patient eGFR
≤ 30 mL/min
Malovrh M. Contrib Nephrol. 2015;184:13-23. No
Yes
Physical examination of veins
Vein preservation:
- educational program for
patients, nurses and physicians
Clinical examination
Physical examination of vessels
Proximal compression:
- Visibility
Continuity
Distension
Side branches
Arm or thoracic collaterals
Medical history and concomitant diseases:
Age
Gender
Hypertension
Diabetes
Cardiac diseases
Peripheral arteries
diseases
Veins
Arteries
Tourniquet placed:
- Visibility
Continuity
Distension
Side braches
Arm or thoracic
collaterals
- Quality of arterial
pulse
Blood pressure at both
arms
- Allen test
Duplex ultrasound
VEINS
- Internal diameter (>2-2.5 mm)
Internal diameter with inflated cuff – increasing
for ≥ 0.4 mm or > 15% (distensibility) (Figure 3)
- Depth of vein ≤6 mm
- Quality of vein wall – no fibrotic changes
No side branches or ligation them during
surgery
- Changing of Doppler waveform during respiration -
increasing during inspiration (Figure 4)
ARTERIES
Internal diameter (>2-2.5 mm)
Calcification (severe-move towards upper
part of forearm)
- Doppler flow velocity (≥ 25 cm/s)
Resistance index (RI) at reactive hyperemia-
≤ 0.7 or change of HRF to LRF (Figure 5)

23. Physical examination of vessels
CKD patient eGFR
≤ 30 mL/min
Malovrh M. Contrib Nephrol. 2015;184:13-23. No
Yes
Physical examination of arteries
Vein preservation:
- educational program for
patients, nurses and physicians
Clinical examination
Physical examination of vessels
- Quality of pulse
Blood pressure on both arms
- Allen test???
Medical history and concomitant diseases:
Age
Gender
Hypertension
Diabetes
Cardiac diseases
Peripheral arteries
diseases
Veins
Arteries
Tourniquet placed:
- Visibility
Continuity
Distension
Side braches
Arm or thoracic
collaterals
- Quality of arterial
pulse
Blood pressure at both
arms
- Allen test
Duplex ultrasound
VEINS
- Internal diameter (>2-2.5 mm)
Internal diameter with inflated cuff – increasing
for ≥ 0.4 mm or > 15% (distensibility) (Figure 3)
- Depth of vein ≤6 mm
- Quality of vein wall – no fibrotic changes
No side branches or ligation them during
surgery
- Changing of Doppler waveform during respiration -
increasing during inspiration (Figure 4)
ARTERIES
Internal diameter (>2-2.5 mm)
Calcification (severe-move towards upper
part of forearm)
- Doppler flow velocity (≥ 25 cm/s)
Resistance index (RI) at reactive hyperemia-
≤ 0.7 or change of HRF to LRF (Figure 5)

24. Physical examination of vessels
CKD patient eGFR
≤ 30 mL/min
Malovrh M. Contrib Nephrol. 2015;184:13-23. No
Yes
Duplex ultrasound
Vein preservation:
- educational program for
patients, nurses and physicians
Clinical examination
Physical examination of vessels
VEINS
- Internal diameter(>2-2.5 mm)
Internal diameter after compression–
increase for ≥ 0.4 mm ali > 15% (distensibility)
- Depth of vein (≤6 mm)??
- Quality of vein wall – no fibrosis
No side branches
Change of Doppler signal
during deep inspiration
Medical history and concomitant diseases:
Age
Gender
Hypertension
Diabetes
Cardiac diseases
Peripheral arteries
diseases
Veins
Arteries
Tourniquet placed:
- Visibility
Continuity
Distension
Side braches
Arm or thoracic
collaterals
- Quality of arterial
pulse
Blood pressure at both
arms
- Allen test
Duplex ultrasound
VEINS
- Internal diameter (>2-2.5 mm)
Internal diameter with inflated cuff – increasing
for ≥ 0.4 mm or > 15% (distensibility) (Figure 3)
- Depth of vein ≤6 mm
- Quality of vein wall – no fibrotic changes
No side branches or ligation them during
surgery
- Changing of Doppler waveform during respiration -
increasing during inspiration (Figure 4)
ARTERIES
Internal diameter (>2-2.5 mm)
Calcification (severe-move towards upper
part of forearm)
- Doppler flow velocity (≥ 25 cm/s)
Resistance index (RI) at reactive hyperemia-
≤ 0.7 or change of HRF to LRF (Figure 5)

25. Physical examination of vessels
CKD patient eGFR
≤ 30 mL/min
Malovrh M. Contrib Nephrol. 2015;184:13-23. No
Yes
Duplex ultrasound
Vein preservation:
- educational program for
patients, nurses and physicians
Clinical examination
Physical examination of vessels
Arteries
- Internal diameter(>2-2.5 mm)
Calcifications
Doppler flow velocity (> 25 cm/s)
RI at reactive hyperemia<0.7
or change of HRF to LRF
Medical history and concomitant diseases:
Age
Gender
Hypertension
Diabetes
Cardiac diseases
Peripheral arteries
diseases
Veins
Arteries
Tourniquet placed:
- Visibility
Continuity
Distension
Side braches
Arm or thoracic
collaterals
- Quality of arterial
pulse
Blood pressure at both
arms
- Allen test
Duplex ultrasound
VEINS
- Internal diameter (>2-2.5 mm)
Internal diameter with inflated cuff – increasing
for ≥ 0.4 mm or > 15% (distensibility) (Figure 3)
- Depth of vein ≤6 mm
- Quality of vein wall – no fibrotic changes
No side branches or ligation them during
surgery
- Changing of Doppler waveform during respiration -
increasing during inspiration (Figure 4)
ARTERIES
Internal diameter (>2-2.5 mm)
Calcification (severe-move towards upper
part of forearm)
- Doppler flow velocity (≥ 25 cm/s)
Resistance index (RI) at reactive hyperemia-
≤ 0.7 or change of HRF to LRF (Figure 5)

26. Cooperation with vascular surgeons
Role of nephrologist in period of surgery:
Cooperation with vascular surgeons
Cooperation with nephrologists-vascular access
surgeons

27. - depends from tradition - interes of surgeons
DIALYSIS NURSE
RADIOLOGIST
VASCULAR SURGEON
NEPHROLOGIST
- depends from tradition
- interes of surgeons
- financial situation etc.

28. NEPHROLOGIST
VA SURGEON
ULTRASOUND
DIALYSIS PHYSICIAN

29. Who should perform VA surgery?
In the world there are no uniform views
Mostly surgical VA programme are:
Performed by young surgeons
Without continuity
Small and less spectacular surgery

30. Advantages of system “nephrologist-access surgeon”:
Physical and US evaluation of patient by dedicated nephrologists
On time planned VA construction
Surgery could be done at any time: no dependence on capacity of operating theaters and anesthesia teams
In case of VA dysfunction, surgical intervention like thrombectomy, can be done immediately after finding before starting HD and after successful intervention HD can be started on same day without use of CVC

31. Nephrologist – VA surgeon: Yes or No?
If they are interested in and have manual skills
Education at VA surgeon or nephrologist-VA surgeon with experience is required
At least 100 interventions is needed, attraction of VA surgery becomes between 300 and 500 operations
Awareness of risiko is important: "winning" and ”loosing" are very close "neighbors"
Self-criticism and modesty is important No
If all this is not
If a good cooperation with the surgeons

32. Role of nephrologist in period after VA construction:
Period immediately after surgery
Period of maturation

33. Period immediately after VA construction:
VA could stop to work:
Spasm
Hypotension
Disturbed outflow by vein compression
Following VA function by periodic :
Palpation of thrill
Listening of bruit
Early intervention by a gentle massage, infusion of plasma expander and heparin i.v. could be useful

34. Period of VA maturation:
Critical first 4 weeks
Dialysis nurses and nephrologists should evaluate VA clinically to determine whether it has mature sufficiently to use for HD
Early diagnostics and intervention for fistula maturation minimize catheter use and its associated complications

35. Role of nephrologists following of VA function during HD treatment:
Nephrologists should be trained to recognize VA problems:
To pay attention on the quality of HD treatment
based on clinical signs and laboratory tests
Post-puncture bleeding
Decrease or critical reduction of arterial blood
flow or increase of venous pressure during HD

36. Role of nephrologists following of VA function during HD treatment:
Each VA should be evaluated by physical examination before cannulation at each HD treatment.
Physical examination is easily learned, easily performed, quickly done and economical.
US is an additional diagnostic method for detection of these problems early and progression can be prevented by interventional radiology or surgery.

37. Pysical examination
Palpation of thrill
Listening of murmur

38. Vein (outflow) stenosis Ischemia Aneurysm and pseudoaneurysm Infection
Late complications of functioning and
used AVF
Thrombosis
Vein (outflow) stenosis
Ischemia
Aneurysm and pseudoaneurysm
Infection
Recirculation

39. Clinical evaluation of stenosis

43. Central vein stenosis

44. Physical examination of side branches and their importance:

45. Clinical evaluation of recirculation
The pressure on the vessel or graft between the two needles in the course of HD
In the normal state, the changes are minimal or not at all

46. Recirculation as a consequence of disturbances in the drain (venous stenosis)
Venous pressure will be increased,
Arterial pressure becomes somewhat more negative - less the flow from venous part

47. Recirculation as a consequence of poor inflow
(arterial stenosis or bad artery)
Arterial pressure drops - more negative due to reduced inflow from venous part
Venous pressure does not change or very little
The investigation is not possible, if the reason is excessively close of the needles

48. Role of nephrologist in checking of VA cannulation
The rope ladder pattern
The area puncture pattern
The buttonhole pattern

49. CONCLUSION
1. Besides specific therapy of CKD patients, nephrologists at their daily work are faced with the problem of VA at these patients when they will need treatment or are already treated with chronic HD.

50. CONCLUSION
Placement and adequate maturation of VA before initiation of HD therapy require:  Timely patient and staff education and counseling, including vein preservation  Selection of preferred renal replacement modality  Physical and ultrasound assessment of vessels  Selection of VA type and location  Creation of VA at least several weeks or months in advance of its expected need .

51. CONCLUSION
In an ideal situation, creation of VA is an interdisciplinary task and nephrologists are who integrates the activities of dialysis nurse, ultrasonographer, surgeon and interventional radiologist.

52. CONCLUSION
4. In no such ideal situation and lack of interested surgeons, nephrologists have to be involved in physical examination, noninvasive ultrasound examination and VA surgery.

53. CONCLUSION
Monitoring of VA by nephrologist and dialysis nurse should be performed prior to each cannulation by physical examination to detect low flow, hyperpulsatility, abnormal thrills or bruits and skin lesions. In this way, we can achieve timely intervention and prevent final failure of VA.

54. AV fistula or graft?!! Start of treatment? Choice of method?
Dialysers ?
Therapy?
Machines?
AV fistula
or graft?!!
Diagnostic ??

55. Ljubljana is inviting you at 10th VAS Congress in April 2017
THANK YOU FOR
YOUR
ATTENTION
Ljubljana is inviting you at
10th VAS Congress in April 2017