P1252428293iZEJP - PowerPoint PPT Presentation

1 / 61
About This Presentation
Title:

P1252428293iZEJP

Description:

Surgical Revision. 4. Vascular Access ... K/DOQI Suggested Technology ... Surgical Revision. 53. Flow-Guided AV Access Revision. In the Failing Access ... – PowerPoint PPT presentation

Number of Views:238
Avg rating:3.0/5.0
Slides: 62
Provided by: mattwo2
Category:

less

Transcript and Presenter's Notes

Title: P1252428293iZEJP


1
Presentation for Tri-Service General
Hospital July 22nd, 2008
2
Flow-BasedVascular Access Management
A Quantitative approach to preserving access
patency A patients link to life
3
Flow-Based
  • Surgical Creation
  • of the access
  • Hemodialysis
  • Surveillance
  • Angioplasty or
  • Surgical Revision

4
Vascular Access Management Tools
Intraoperative Flowmeter
Endovascular Flowmeter
Hemodialysis Monitor
5
Flow-based Access Creation
6
HT300-Series Flowmeters
  • Mean Volume Flow Digital Display
  • Wave-Form printer
  • FlowSound
  • Inversion button (/-)

Above - HT313 , Below -HT323
7
Transonic (FMV) Vascular Flowprobes
  • Available in a wide range of sizes (1.5 to 14
    mm)
  • Reusable
  • Steam, EtO and Sterrad Sterilizable

8
Transit-Time Ultrasound (TTU)
9
TTU
Difference between T-1 and T-2 is a phase change
proportional to volume Flow
10
ValidationTransit-Time Ultrasound
  • (r 0.930.95) between Transonic TTU Flow
    measurements and True Flow in an experimental
    model

Beldi G, Transit time flow measurement
experimental validation and comparison of three
different systems. Ann Thorac Surg
200070212217.
11
Clinical Technique
  • Skeletonize Vessel
  • Select Flowprobe for a loose fit.
  • Use Acoustic Gel
  • Vessel should fill 60-95 of probe lumen
  • Keep vessel perpendicular to the probe (Dont
    Twist)

12
Movies (If available)
  • Applying Gel
  • Applying Flowprobe to Vessel
  • Flowsound
  • Documenting Waveform

13
End-to-side anastomosis
Measure Venous Outflow
14
Side-to-Side Anastomosis
Measure Venous Outflow
15
Clinical Results - Fistulas
  • Johson et al
  • 227 Fistulas over 4 years
  • Measured Flow 5-10 minutes after vascular
    anastomosis
  • Johnson, CP et al, Prognostic Value of
    Intraoperative Blood flow Measurements
  • in Vascular Access Surgery, Surgery
    124(4)729738, 1998.

16
Fistula Flow Patency Results
Flow Measurements taken 5-10 minutes after anastomosis Failure within 30 days Requiring Intervention Failure within 30 days Requiring Intervention
Radiocephalic Fistula Radiocephalic Fistula Radiocephalic Fistula
Flow lt 170 ml/min 56 P.001
Flow gt 170 ml/min 15 P.001
Brachiocephalic Fistula Brachiocephalic Fistula Brachiocephalic Fistula
Flow lt 280 ml/min 64 P.01
Flow gt 280ml/min 18 P.01
Johnson, CP et al, Prognostic Value of
Intraoperative Blood flow Measurements in
Vascular Access Surgery, Surgery 124(4) 729738,
1998.
17
AV Fistula Guidelines
Flow rates lt 100 ML/min Abandon Immediately, unless correctable
Flow between 100 and 300 mL/min Monitor Closely. At risk for early failure
Johnson, CP et al, Prognostic Value of
Intraoperative Blood flow Measurements in
Vascular Access Surgery, Surgery 124(4)729738,
1998.
18
Clinical Results - Fistula
  • Berman 72 AV fistulas over 12 months
  • Berman, SS et al, Predicting Arteriovenous
    Fistula Maturation with INtraoperative Blood Flow
    Measurements Western Vascular Socitey 22nd
    Annual Meeting, Sept, 8-11, 2007, Kohala Coast,
    Kona, HI.

19
Fistula Guidelines
AV Fistula Type Threshold to predict Maturation
Radiocephalic 179 mL/min
Brachiocephalic 308 mL/min
Berman, SS et al, Predicting Arteriovenous
Fistula Maturation with INtraoperative Blood Flow
Measurements Western Vascular Socitey 22nd
Annual Meeting, Sept, 8-11, 2007, Kohala Coast,
Kona, HI.
20
PTFE Grafts
Air in the graft interstices block ultrasound
transmission. Therefore, measure at the distal
outflow of the graft.
21
Clinical Results - Grafts
  • Johnson et al162 PTFE grafts
  • Johnson, CP et al, Prognostic Value of
    Intraoperative Blood flow Measurements in
    Vascular Access Surgery, Surgery 124(4)729738,
    1998.

22
PTFE Graft Flow Guidelines cont.
lt 250 mL/min Consider abandoning
250-400 mL/min Consider prophylactic anticoagulation
Johnson, CP et al, Prognostic Value of
Intraoperative Blood flow Measurements in
Vascular Access Surgery, Surgery 124(4)729738,
1998.
23
Flow-QC Measurements
  • Quick, accurate, and easy to perform
  • May indicate corrections during surgery
  • Can predict the ultimate survival of an AV access

24
Flow-based Surveillance
during Hemodialysis
25
K/DOQI
National (USA) Kidney Foundation Kidney Disease
Outcomes Quality Initiative
  • Promotes new standards of care in order to treat
    all forms of kidney disease and reduce the number
    of dialysis patients.

http//www.kidney.org/PROFESSIONALS/kdoqi/guidelin
e_upHD_PD_VA/index.htm
26
K/DOQI Goal
  • Detect access dysfunction prior to access
    thrombosis.

http//www.kidney.org/PROFESSIONALS/kdoqi/guidelin
e_upHD_PD_VA/va_guide4.htm
27
K/DOQI Suggested Technology
  • Indicator dilution (Transonic) flow measurements
    are the preferred method of A-V graft and fistula
    surveillance.

28
Indicator Dilution Flow Measurements
29
Transonic Flow-QC Hemodialysis Monitor
  • The Standard of Care for the ESRD patient

30
HD Monitor Parameters
  • Dialysis Adequacy
  • Delivered Blood Flow
  • Recirculation
  • Vascular Access Flow
  • Cardiac Output

31
Access Flow Measurement (Blood Lines are
Reversed)
32
K/DOQI Guidelines
33
K/DOQI Guidelines for Monitoring AV Grafts and
Fistulas
  • Access flow lt 600 ml/min, the patient should be
    referred for fistulagram.
  • Access flow lt 1000ml/min that has decreased by gt
    25 over 4 months should be referred for
    fistulagram.

34
Monthly Access Flow Trending
K/DOQI Guideline lt600 ml/min
Documented Intervention
35
Clinical Results
  • Gambro Study
  • McCarley Study

36
Gambro Study
An 18-month Gambro Study of 254 patients using a
multidisciplinary approach to vascular access
care resulted in
  • 44 decrease in thrombosis.
  • Significant improvements in clinical outcomes.
  • Decrease in hospitalizations.

Reference Duda, CR, Spergel, LM, Holland, J,
Tucker, T, Bosch JP, Bander, SJ. A
Multidisciplinary Vascular Access Care Program
(VACS) Enables Implementation of Dialysis
Outcomes Quality Initiative (DOQI), JASN
Abstracts, Vol. 10, p. 206A, 1999.
37
Vascular Access Blood Flow Monitoring Reduces
Access Morbidity and Costs
  • Patricia McCarley, Rebecca L. Wingard, Yu Shyr,
    William Pettus, Raymond M. Hakim, and T. Alp
    Ikizler
  • Vanderbilt University Medical Center, Dialysis
    Clinics, Inc., Renal Care Group, Inc.

Kidney International, Vol. 60 (2001), pp.
1164-1172
38
Three-Phase Study
Phase Duration Monitoring Technique
I 11 Months None
II 12 Months Dynamic V.P.
III 10 Months Transonic HD01
132 Hemodialysis Patients with A-V grafts or
fistulas.
39
(No Transcript)
40
(No Transcript)
41
Europe
  • Objective monitoring of access function should
    be performed regularly by measuring access flow.

European best practice guidelines on hemodialysis
Guideline 5. Surveillance of Vascular Access.
ERA/EDTA. Nephrol Dial Transplant, 2007 22(Suppl
2) ii99. Transonic Reference HD7450A
42
Japan
  • Regular monitoring of shunt flow in
    haemodialysis patients has become extremely
    important.

Clinical Evaluation of New Non-Invasive Shunt
Flow Measurement Device. Satoshi YAMAGUCHI1,
Noriko OKUMURA1, Izumi AMANO1 Department of Blood
Purification, Tenri Hospital. 42nd Annual Meeting
of the Japanese Society for Artificial Organs
October 6, 2004
43
Flow-QC in HD
Preserve an Access - Save a Live
44
Flow-based AV Access Intervention
45
Why measure flow during Angioplasty?
  • Intra-access blood flow fails to normalize
    after angioplasty in 20-30 of patients.

Vesely, T.M., et al, "Use of a catheter-based
system to measure blood flow in hemodialysis
grafts during angioplasty procedures," J Vasc
Interv Radiol, 13(4) 371-378, 2002.
46
HVT100 Endovascular System
  • HVT100 system provides quantitative assessment
    during angioplasty
  • The data allows the Radiologist to make
    adjustments before the patient leaves the IR
    suite.

HVT100 Endovascular Flowmeter and ReoCath Flow
Catheter
47
Flow-Guided Angioplasty
  • Measure baseline flow before
  • Angioplasty
  • Measure flow after angioplasty to confirm success.

48
Catheter Types
Antegrade
Retrograde
49
K/DOQI Guidelines
50
Clinical Results
  • Post-angioplasty blood flow is predictive of
    subsequent graft patency
  • Murray, BM et al, Access Flow after Angioplasty
    Predicts Subsequent Arteriovenous Graft
    Survival, J Vasc Interv Radiol 17303-309, 2006.
    HD2020A
  • Success achieved in restoring flow, as measured
    during the intervention usually predicts good
    immediate outcomes in the HD unit.
  • Krivitski , NM Access Flow Measurement during
    Surveillance and Percutaneous Transluminal
    Angioplasty Intervention, Sem Dial 16(4)
    304-308, 2003.

51
Flow-Guided Angioplasty
  • Confirms the Need
  • Confirms the Success

52
Flow-based AV Access Surgical Revision
53
Flow-Guided AV Access Revision
  • In the Failing Access
  • Flow measurements guide a revision
  • and confirm its success
  • When Access Flow Is Too High
  • In banding of fistulas, flow measurements
    confirms that flow is reduced to an acceptable
    level.

54
Ischemic Steal Syndrome
DRIL Bypass
Distal revascularization interval ligation
(DRIL) is gaining acceptance as an optimum
way to manage ischemic steal syndrome (ISS).
55
Flow Measurements during DRIL
  • Confirm the presence of steal at DRIL onset
  • Confirm flow augmentation to the forearm after
    the bypass is completed.

Illig, KA et al, Hemodynamics of Distal
Revasularization Interval Ligation, Ann Vasc
Surg 2005 19199-207.
56
Flow-based Vascular Access Management
57
Conclusion
  • Review of available evidence would suggest that
    access flow measurements are the best tests
    currently available to screen for access
    dysfunction, and as preventative interventions,
    such as angioplasty and surgery, are successful,
    they should be regarded as the present standard
    of care.

Garland, J.S. et al, Are hemodialysis access
flow measurements by ultrasound dilution the
standard of care for access surveillance?
Advances in Renal Replacement Therapy 2002 9(2)
91-98. HD263A
58
Tissue Perfusion
Extra-Corporeal
Research
Cardiovascular
Interventional Radiology
VAD performance / OEM
Neuro
Dialysis
59
Major Perivascular Flow Measurement Applications
Vascular Surgery AV Fistulas  Grafts radial art
ery brachial artery venous outflow of graft Abdom
inal  renal bypass aorta iliac shunt
portal-caval shunt spleno-renal shunt  Lower E
xtremity Bypass  profunda femoris  common femoral
popliteal tibial  Carotid Endarterectomy common 
carotid artery  internal carotid artery  external 
carotid artery Pruit-Inhara Shunt Javid Shunt
Cardiac Surgery  CABG On  Off Pump arterial co
nduits  saphenous vein Cardiac Output  adult asce
nding aorta adult pulmonary artery pediatric heart
Transplant Surgery Liver hepatic artery portal 
vein Kidney renal artery  renal vein  Pancreas 
common iliac artery  Cerebrovascular
Neurosurgery Cerebral arteries EC-IC Bypass
60
Transonic - Proven
  • 25 Years of Excellence
  • Referenced in over 4,000 publications
    (www.transonic.com)
  • We are here to help with application and service
    needs

61
Thank You
Write a Comment
User Comments (0)
About PowerShow.com