1. The Good Old Days of Dialysis Access Surgery Eric D. Ladenheim MD

2. Support gratefully acknowledged from David Kennedy W. L. Gore. & Associates, Inc

3. Overview of talk  There are a lot more AV Fistulas than in the good old days and more are coming.  Some AV Fistulas and Grafts have weird anatomy.  The Dialysis Access Surgeon can help make cannulation much easier for you and your patient.

4. The Good Old Days Ladenheim 1995 - 1998

5. How Did the USA Compare to the Rest of the World Prior to 2003?

6. The Good Old Days Ladenheim 1995 - 1998

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

10. Why is the AVF rate low if it is the “gold standard”?  50% of patients start dialysis emergently, thus catheters are inserted for a quick vascular access to initiate hemodialysis  Patients may resist changing to an AVF due to fear of needles  Reimbursement for an AV graft is higher AV Grafts can be used sooner than an AV fistula AV Grafts can be used sooner than an AV fistula

12. Madness and Folly Ladenheim 1999 – 2001

14. Where we were in 2003? 33 % Prevalent AVF Northern Cal Region 17

15. Have we made any progress? Source: March 2006 Network Provider Fistula First Reports Region 17 -- Northern California 46.3%

16. End Stage Renal Disease Network Regional Map Prevalent 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 Board 100% of facilities may not of reported in each Network Rates across USA & Possessions US US Rate =US Rate =

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

18. New and Improved Dr. Ladenheim 2004 to 2007

21. Overview of talk  There are a lot more AV Fistulas than in the good old days and more are coming.  Some AV Fistulas and Grafts have weird anatomy.  The Dialysis Access Surgeon can help make cannulation much easier for you and your patient.

22. Drawing courtsey of James F. Whiting, MD22 Sites for Native Fistulas

26. ( Very Much )

28. Collaborative Care of Vascular Access  Surgeons have a role as vascular access advocates through:  diagramming new accesses & labeling arterial limb  communicating specific access orders directly to the nurses  visiting the dialysis units to do patient & staff education and to familiarize staff c surgeon’s point of view  be readily accessible for consultation

29. Surgeon’s Role: Diagramming accesses and marking blood flow direction

30. Available for Consultation  Failure of fistulas to mature  High negative pressures  Difficult cannulation situation  Re-Mapping of Fistulas  Ligation of parasitic veins  Monitoring of aneurysms and pseudoaneurysms  Dealing with hematomas  Evaluation of swollen extremity  Poor Blood flow  Poor dialysis adequacy  Surgical Follow up after graft thombosis