Use of ultrasound for AVF angioplasty. Time to get rid-off the - - PowerPoint PPT Presentation

Use of ultrasound for AVF angioplasty. Time to get rid-off the C-arm?

Olivier Pichot - Carmine Sessa Grenoble

Disclosure I do not have any potential conflict of interest for this presentation

Fluoroscopic guidance

▪ Dedicated equipment

• X Ray room
• C-arm

▪ Radiation exposure

• Patient
• Medical team

▪ Radiation protection

• Lead apron
• Shielding booth
• Film badges

▪ Contrast agent injection

Is it possible to resolve these issues?

▪ Radiation exposure:

• ALARA (As Low As Reasonably

Achievable)

▪ Contrast agents:

• CO2
• Contrast dilution

▪ An ideal technology ?

• No radiation
• No contrast
• Good flux visualisation
• Hemodynamical information
• Flow
• Velocities
• Anatomical information
• Vein wall
• Surrounding tissues
• Continuous monitoring of the

procedure

Ultrasound

✔ No radiation ✔ No contrast ✔ Good flux visualisation ✔ Hemodynamical

information

✔Flow ✔Velocities

✔ Anatomical

information

✔Vein wall ✔Surrounding tissues

✔ Continuous

monitoring of the procedure

In practice: Preoperative duplex examination

▪ AVF DU analysis ▪ Mapping ▪ Choice of the vascular access site ▪ Choice of the appropriate balloon

Preoperative DUS and PTA management: Doelman 2005)

• Optimize the choice of the cannulation site in 38% of cases
• Reduce the number of access punctures
• Avoid extra session to perform PTA and shorten examination time
• Avoid extra burden for the patient

« Surgery like » set-up & Sterilized supplies

• 1. Vascular access

▪ Non systematic EG ▪ Mandatory (very useful)

• Drainage vein access
• Maturation delay
• Retrograde catheterization
• Obesity
• Brachial artery access

• 2. Introducer tip positioning

▪ Mandatory (very useful) if the distance between the vein access site & the stenosis is short

2 cm

• 3. Catheterization

• 4. Balloon positioning

• 4. Balloon positioning

• 5. Balloon inflation

• 6. Results evaluation

• 6. Results evaluation

▪131 PTA in 86 patients:

• Distal AVF

61%

• Cephalic vein

82.4%

▪ Echo guidance: 81.7%

• Forearm

72.9%

• Arm

27.1%

▪ Fluoroscopic guidance: 18.3%

• Ceph. arch or prox. v.

75%

• EG unavailable

25%

1,9 93,5 0,9 3,7 3,7 Catheterization failure (n=2) Stenosis relief (n=100) RX conversion (n=1) Residual stenosis (n=2) or thrombosis (n=2)

EG PTA Results n= 107 (%)

Complications

▪ Cephalic v. rupture 1.9 % (n= 2) ▪ Compressive perivenous hematoma 2.8 % (n= 3)

▪Extended dissection: 19.6% (n=21)

• Successful prolonged compression

17.8 % 19

• Residual stenosis

1.8 % 2

▪Recoil (vein stenosis) 9.3 % (n=10) ▪Vein spasm (access site) 1.8 % (n=2)

Echoguidance pro and cons

▪ No radiation no contrast ▪ “In office” practice ▪ Reduction of the duration (and cost) of the procedure

Echoguidance pro and cons

▪Limitations:

• Cephalic arch
• Arteries calcifications
• Central veins

Cephalic arch Radial artery Brachio cephalic vein

Echoguidance pro and cons

▪Intrinsic improvements:

• Security and accuracy of the

vascular access

• Real time monitoring of all the

procedure steps

• Real time monitoring of all the

procedure outcome

• Anatomical
• Hemodynamic +++
• Vein (or catheter) mobilization

maneuver

The future: to convince…

KDOQI CLINICAL PRACTICE GUIDELINE FOR VASCULAR ACCESS: 2018 AJKD SUBMISSION DRAFT April 2019

The future: to educate…

New semiology Training phantoms Fellowship New practice

Echoguidance is already a routine practice for the new medical generation

😊

▪ Anesthesiologist:

Local anesthesia

▪ Nephrologist:

CVC insertion

▪ Carcinologist:

PICC-Line insertion

▪ Nurse:

Peripheral IV catheter insertion

▪ Vascular surgeon and radiologist:

Arterial and venous access

▪ Phlebologist:

Endovenous treatment guidance

Echoguidance for AVF PTA is the next step !