1. Ten Tips for Dialysis Management
by Anthony C. Venbrux, MD
Professor of Radiology and Surgery
Director, Cardiovascular and Interventional Radiology
The George Washington University
Medical Center
Washington, DC

2. Anthony Venbrux, MD DISCLOSURES
I have no real or apparent conflicts of interest to report.

4. Objectives Discuss clinical aspects.
Review current access maintenance procedures:
Surgical .
Interventional.

5. Objectives Interventional therapeutic options: PTA.
"Mechanical" thrombectomy/thrombolysis.
Thrombolytic therapy.
Combination therapy.
Stents.
Tunneled hemodialysis catheters.

6. The Role of The Interventional Physician
Define anatomy.
Perform baseline and follow-up studies.
Percutaneous interventions:
PTA.
Thrombolytic therapy.
"Mechanical” or pharmacomechanical “thrombolysis.”
Stents.
Hemodialysis catheter placement.

7. One

8. Understand the Anatomy

9. Permanent Hemodialysis Access
Arteriovenous (AV) fistula.
Prosthetic graft.
Approximately 95+% of the problem is on the venous side!

10. Brescia-Cimino Fistula
Autogenous AV Fistula
Brescia-Cimino Fistula
Radial artery – cephalic vein.
Superior patency.
USA: Only 25% of vascular accesses are native fistulae.

11. "Synthetic Bridge Grafts"
Prosthetic Graft
"Synthetic Bridge Grafts"
Forearm Loop: Brachial artery to cephalic or basilic vein.
Arm Graft: Brachial artery to axilliary vein.

12. Prosthetic Graft Lower patency. Greater physician involvement.
USA: Majority of vascular accesses are prosthetic grafts.

13. Mayo Foundation

14. Han, Kuo-Ming, L E Duijm, G R P Thelissen, et al
Han, Kuo-Ming, L E Duijm, G R P Thelissen, et al . Failing Hemodialysis Grafts: Evaluation of Complete Vascular Tree with 3D Contrast-enhanced MR Angiography with High Spatial Resolution . … RSNA,

15. HeRO Graft, Hemosphere Inc, Minneapolis MN

16. Two

17. Physical Exam

18. Physical Examination of Graft or Fistula
"Thrill"
"Pulse"
"Neither"

19. Failing Dialysis Access
Physical examination:
Palpation of graft.
Arm swelling.

20. Symptomatic Central Venous Stenosis
Arm swelling.
Delayed healing of incisions.

21. Three

22. Understand Dialysis Parameters

23. Failing Dialysis Access
Dialysis parameters:
Venous pressures.
Urea recirculation time.

24. Four

25. Understand the importance of Screening

26. Failing Dialysis Access
Noninvasive imaging.
Ultrasound.
Invasive procedures.
Contrast studies.

27. Contrast Evaluation Patent: Image entire fistula or graft.
Image central venous system.
Thrombosed:
Do not inject contrast.
Risk of distal emoblization.

28. Five

29. Know Your Options

30. The Failing Access Surgical. Percutaneous interventions: PTA.
Thrombolytic therapy.
"Mechanical” or pharmacomechanical “thrombolysis.”
Stents

31. Thrombosed Access Graft
Surgical.
Percutaneous.
Crossed catheter technique.
Thrombectomy
Thrombolytic therapy.
Catheter Directed Infusion.
"Pulse Spray" Pharmacomechanical.
Intervention.
PTA first; use stents as a last resort.

32. Mayo Foundation

33. "Mechanical" Declotting
Average dialysis graft clot volume cc.
Avoid in a patient with:
COPD.
Right heart failure.
Thrombus extending into the central venous system.
Trerotola SO. Venous Interventional Radiology with Clinical Perspectives, Theime, NY 1996

34. Central Venous Pressure Measurements
Patent Fistula or Graft

35. Six

36. Know the Natural History

37. Thrombosed Access Graft
Surgical series:
A cause is found 50% of the time.
Radiologic series:
A cause is found approximately 90% of the time.

38. History of Prior Subclavian Vein Dialysis Catheters
Moderate or severe subclavian vein stenosis found in 40% of patients.
Surrat, R, et al, AJR 1991;156:

39. Seven

40. Know the Alternatives

42. Eight

43. Be Realistic

44. "Mechanical" Thrombolysis
Initial patency (“Lysis”) achieved in 94% of patients.
Clinical success (patency at 7 days) 59%.

45. Nine

46. Be Creative

51. Ten

52. Avoid Central Venous Stents

56. Take Home Points