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Introduction
• 300 – 400: 1 000 000 worldwide
• CRD in Bulgaria is nearly twicehigher than the average for the EU -almost 26%
Morbidity of Chronic RenalDisease:
IntroductionPermanent vascular access
(PVA) includes all methods ofrealizing an arteriovenous
anastomosis (fistula) - AVF.
Complications of the AVF:
• hemodynamically significant stenosis;• infection of the PVA;
• thrombosis ;
• pseudoaneurism;• rupture of the PVA.
Introduction
Endovascular treatment ofPVA is a safer alternative of
the operative one.
Introduction
IntroductionHemodynamically significant stenosis is
present when the normal vasculardiameter is reduced by 50% or more.
• increased static or dynamic pressure;• decreased blood capacity;• groundless dialysis cleansing;• swallowing of the extremity.
Introduction
Stenosis found before it thromboses iseasier to be treated than post-
thrombotic one and shows 79%reliability. Reliability of post-
thrombotic treatment of the stenosisdecreases to 40%.
PTA
The preferred method of treatment foreither arterial or venous stenosis of PVA is
Percutaneous Transluminal Angioplasty(PTA).
PTAIndicator of dysfunction:
• greater than 25% decrease in flow over3-4 month period;
• elevated urea recirculation;• arm swelling;• poor thrill/pulsatile;• poor maturation of fistula.
PTA
Balloons:
• High-pressurenon-compliant;
• “Coronary”type balloons;
• Cuttingballoons;
• Oversizedballoons.
PTA + Stenting
Stenting combined with PTA isindicated when elastic stenosis is
present or relapse of stenosis for aperiod of 3 months.
Stents:
• Self-expandingstents;
• Bare stents;• Covered stents;• Balloon-
expandablestents.
PTA + Stenting
PTA
The typical endpoint is restoration ofnormal trill to the fistula. A successful
angioplasty will have complete effacementof the balloon waist and result in 0 - 30%
residual narrowing.
PTAContraindications:
• Infected AVF;• Uncorrectable severe coagulopathy;• Severe allergy to iodinated contrast
agents;• Percutaneous intervention on a
newly placed graft.
Treatment of clotted AVF is eitherendovascular thrombectomy (ET)
or thrombolysis.
Sweeping thrombus from the occludedgraft into the central venous circulation
Pulmonary circulation embolization
ET Balloon-Sweep
Contraindications:
• Patients with cardiopulmonarycompromise;
• Known right-to-left intracardiac shunt,especially with pulmonary hypertension.
ET Balloon-Sweep
Endovascular thrombectomy is mostcommonly performed by using
thromboaspiration, combined withangioplasty. It is most useful with
fresh thrombus .
ET Thromboaspiration
Mechanical thrombectomydevices are designed to removethrombus quickly, effectively,and safely from hemodialysis
grafts.
ET Devices
Recirculation-type devices create ahydrodynamic vortex, which homogenizes
the thrombus converting it into slurry.
ET Devices
Recirculation-type devices include:
• Helix• Xpeedior• Oasis catheter• Hydrolyser catheter• Thrombex PMT
ET Devices
The non-recirculation-type devices use arapidly spinning wire basket or plastic brush
to mechanically fragment the thrombus.
ET Devices
Non-recirculation-type devicesinclude:
• Trerotola-PTD• Thrombolytic brush catheter(Cragg/Castaneda)
ET Devices
Thrombolysis is taken in considerationmainly in combination with other methods
of endovascular treatment of PVA andespecially during the first couple of hours
after thrombosis.
Thrombolysis
Results
Immediate patency 3-month patency 6-month patency
Angioplasty 0 – 30% residualnarrowing
- 50%
Thrombectomy >85% 40% 20 - 40%
Short-term results:
Results
Long-term patency of vascular access isdependent on the identification and
successful treatment of all significantstenoses.
Long-term Results:
Long-term results should be consideredonly when angioplasty with/without
stenting is performed.
Results
Endovascular therapy requires qualifiedmedical team and adequately equippedoperating room. The medical supplies
needed for these procedures are expensiveand in this sense endovascular treatment
of AVF in Bulgaria is financiallycompromised.
Conclusion
References1. Handbook of Angioplasty and Stenting
Procedures, Techniques in IR series, LeeWatkinson;
2. Съдов достъп. Перитонеална диализа, проф.Д-р Здравко Краев;
3. Dialysis Access: A Multidisciplinary Approach ,Richard James Gray,Jeffrey J. Sands;Endovascular Interventions: A Case-BasedApproach, Robert S. Dieter,Raymond A. Dieter,Jr. ,Raymond A. Dieter, III,AravindaNanjundappa
4. Vascular Surgery, SIXTH EDITION, Robert B.Rutherford MD, FACS, FRCS (Glasg.)
5. Haimovici's Vascular Surgery, 6th Edition
Thank you for yourattention!
???Questions ???