ASDIN 9th Annual Scientific Meeting

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• The views presented reflect those of the author/presenter and do not necessarily reflect those of ASDIN nor serve as an endorsement of safety, efficacy or applicability of said procedure.

Fistula “Side-Branch” Management

Theodore F. Saad, M.D.

Newark, Delaware

Disclosuure

• No relevant conflicts of interest or financial relationships

Fistula Vein Branch Obliteration: Disclaimer

• Skeptic

• Limited data

• Limited practice– >6600 fistula

procedures over 12 years

– 34 accessory vein occlusion

• 28 branch ligation

• 6 coil embolization

Our Fistula RatesESRD Network-4

Voormolen, et al., J Vasc Surg 2009

ASDIN 9th Annual Scientific Meeting

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Accessory Vein Obliteration

• Why?– Or “Why Not?”

• How?

Terminology

• Side branch

• Branch vein

• Accessory vein

• Collateral vein

• Occlusion– Ligation

– Embolization

Why?

• It’s all about flow

Flow entering AVF1000 ml/min

Side branch diverts100 ml/min

Net usable fistula flow900 ml/min

=Functional fistula

Why?

• It’s all about flow

Flow entering AVF600 ml/min

Side branch diverts200 ml/min

Net usable fistula flow400 ml/min

=Marginal fistula

Why?

• It’s all about flow

Flow entering AVF400 ml/min

Side branch diverts200 ml/min

Net usable fistula flow200 ml/min

=Unusable fistula

Where?

• It’s all about flow

Flow entering AVF600 ml/min

Side branch diverts200 ml/min

Net usable fistula flow600 ml/min

=Functional fistula

ASDIN 9th Annual Scientific Meeting

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Assessing Significance of Accessory Veins

• No reliable verified quantitative method– Intra-procedure access flow

• With and without branch occlusion

• Fistula flow is dynamic depending on– Volume status

– Blood pressure

– Cardiac output

• Subjective

Forearm radial-cephalic fistula

Puncture segment

Multiple outflow veins

Large inflow segment accessory vein

Branch Vein Occlusion: How?

• Percutaneous suture ligation*

• Cutdown with circumferential ligature– Access center

– Operating room

• Coil Embolization

*Faiyaz R, Abreo K, Zaman F, Pervez A, Zibari G, Work J. Am J Kidney Dis 2002

Imaging catheter in radial artery

5 French Berenstein catheter advanced into accessory vein

Locating the accessory vein

ASDIN 9th Annual Scientific Meeting

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Accessory Vein Ligation

Imaging catheter advancedretrograde into artery for direct injection

Large branch vein appears to divert “substantial” flow without outflow occlusion

No outflow stenosis

Accessory Vein Ligation

Successfully ligated Branch vein with 2 mm stump

Coil Embolization

• Brand

• Design

• Diameter

• Length

• Deployment technique

• Retrieval

Selective Catheterization of Accessory Vessel

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1st Branch Coiled 2nd Branch Coiled

3rd Branch Coiled 3rd Branch Coiled

Final ResultBranch Vein Management:

Conclusions• May be useful adjunct for fistula

maturation and/or optimization of function in limited subset of patients

• Techniques for ligation or embolization– Depth

– Complexity

– Number