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Surgical vs. Endovascular Management Of Cephalic Arch Syndrome
Surgical vs. Endovascular Management Of Cephalic Arch Syndrome
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CME
Algorithms For Managing Steal Syndrome: When Is Banding Appropriate
Algorithms For Managing Steal Syndrome: When Is Banding Appropriate
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CME
Current Management Of Bleeding Hemodialysis Fistulas: Can The Fistula Be Salvaged
Current Management Of Bleeding Hemodialysis Fistulas: Can The Fistula Be Salvaged
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CME
Challenges And Solutions In Complex Dialysis Access Cases
Challenges And Solutions In Complex Dialysis Access Cases
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CME
Use Of Indirect Access Sites For AV Intervention
Use Of Indirect Access Sites For AV Intervention
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CME
Elevation Or Retunneling For Second Stage Basilic Vein Transposition
Elevation Or Retunneling For Second Stage Basilic Vein Transposition
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Transcript

- So I'd like to thank Dr. Ascher, Dr. Sidawy, Dr. Veith, and the organizers for allowing us to present some data. We have no disclosures. The cephalic arch is defined as two centimeters from the confluence of the cephalic vein to either the auxiliary/subclavian vein. Stenosis in this area occurs about 39%

in brachiocephalic fistulas and about 2% in radiocephalic fistulas. Several pre-existing diseases can lead to the stenosis. High flows have been documented to lead to the stenosis. Acute angles. And also there is a valve within the area.

They're generally short, focal in nature, and they're associated with a high rate of thrombosis after intervention. They have been associated with turbulent flow. Associated with pre-existing thickening.

If you do anatomic analysis, about 20% of all the cephalic veins will have that. This tight anatomical angle linked to the muscle that surrounds it associated with this one particular peculiar valve, about three millimeters from the confluence.

And it's interesting, it's common in non-diabetics. Predictors if you are looking for it, other than ultrasound which may not find it, is calcium-phosphate product, platelet count that's high, and access flow.

If one looks at interventions that have commonly been reported, one will find that both angioplasty and stenting of this area has a relatively low primary patency with no really discrimination between using just the balloon or stent.

The cumulative patency is higher, but really again, deployment of an angioplasty balloon or deployment of a stent makes really no significant difference. This has been associated with residual stenosis

greater than 30% as one reason it fails, and also the presence of diabetes. And so there is this sort of conundrum where it's present in more non-diabetics, but yet diabetics have more of a problem. This has led to people looking to other alternatives,

including stent grafts. And in this particular paper, they did not look at primary stent grafting for a cephalic arch stenosis, but mainly treating the recurrent stenosis. And you can see clearly that the top line in the graph,

the stent graft has a superior outcome. And this is from their paper, showing as all good paper figures should show, a perfect outcome for the intervention. Another paper looked at a randomized trial in this area and also found that stent grafts,

at least in the short period of time, just given the numbers at risk in this study, which was out after months, also had a significant change in the patency. And in their own words, they changed their practice and now stent graft

rather than use either angioplasty or bare-metal stents. I will tell you that cutting balloons have been used. And I will tell you that drug-eluting balloons have been used. The data is too small and inconclusive to make a difference. We chose a different view.

We asked a simple question. Whether or not these stenoses could be best treated with angioplasty, bare-metal stenting, or two other adjuncts that are certainly related, which is either a transposition or a bypass.

And what we found is that the surgical results definitely give greater long-term patency and greater functional results. And you can see that whether you choose either a transposition or a bypass, you will get superior primary results.

And you will also get superior secondary results. And this is gladly also associated with less recurrent interventions in the ongoing period. So in conclusion, cephalic arch remains a significant cause of brachiocephalic AV malfunction.

Angioplasty, across the literature, has poor outcomes. Stent grafting offers the best outcomes rather than bare-metal stenting. We have insufficient data with other modalities, drug-eluting stents, drug-eluting balloons,

cutting balloons. In the correct patient, surgical options will offer superior long-term results and functional results. And thus, in the good, well-selected patient, surgical interventions should be considered

earlier in this treatment rather than moving ahead with angioplasty stent and then stent graft. Thank you so much.

- So my charge is to talk about using band for steal. I have no relevant disclosures. We're all familiar with steal. The upper extremity particularly is able to accommodate for the short circuit that a access is with up to a 20 fold increase in flow. The problem is that the distal bed

is not necessarily as able to accommodate for that and that's where steal comes in. 10 to 20% of patients have some degree of steal if you ask them carefully. About 4% have it bad enough to require an intervention. Dialysis associated steal syndrome

is more prevalent in diabetics, connective tissue disease patients, patients with PVD, small vessels particularly, and females seem to be predisposed to this. The distal brachial artery as the inflow source seems to be the highest risk location. You see steal more commonly early with graft placement

and later with fistulas, and finally if you get it on one side you're very likely to get it on the other side. The symptoms that we are looking for are coldness, numbness, pain, at the hand, the digital level particularly, weakness in hand claudication, digital ulceration, and then finally gangrene in advanced cases.

So when you have this kind of a picture it's not too subtle. You know what's going on. However, it is difficult sometimes to differentiate steal from neuropathy and there is some interaction between the two.

We look for a relationship to blood pressure. If people get symptomatic when their blood pressure's low or when they're on the access circuit, that is more with steal. If it's following a dermatomal pattern that may be a median neuropathy

which we find to be pretty common in these patients. Diagnostic tests, digital pressures and pulse volume recordings are probably the best we have to assess this. Unfortunately the digital pressures are not, they're very sensitive but not very specific. There are a lot of patients with low digital pressures

that have no symptoms, and we think that a pressure less than 60 is probably consistent, or a digital brachial index of somewhere between .45 and .6. But again, specificity is poor. We think the digital pulse volume recordings is probably the most useful.

As you can see in this patient there's quite a difference in digital waveforms from one side to the other, and more importantly we like to see augmentation of that waveform with fistula compression not only diagnostically but also that is predictive of the benefit you'll get with treatment.

So what are our treatment options? Well, we have ligation. We have banding. We have the distal revascularization interval ligation, or DRIL, procedure. We have RUDI, revision using distal inflow,

and we have proximalization of arterial inflow as the approaches that have been used. Ligation is a, basically it restores baseline anatomy. It's a very simple procedure, but of course it abandons the access and many of these patients don't have a lot of good alternatives.

So it's not a great choice, but sometimes a necessary choice. This picture shows banding as we perform it, usually narrowing the anastomosis near the artery. It restricts flow so you preserve the fistula but with lower flows.

It's also simple and not very morbid to do. It's got a less predictable effect. This is a dynamic process, and so knowing exactly how tightly to band this and whether that's going to be enough is not always clear. This is not a good choice for low flow fistula,

'cause again, you are restricting flow. For the same reason, it's probably not a great choice for prosthetic fistulas which require more flow. So, the DRIL procedure most people are familiar with. It involves a proximalization of your inflow to five to 10 centimeters above the fistula

and then ligation of the artery just below and this has grown in popularity certainly over the last 10 or 15 years as the go to procedure. Because there is no flow restriction with this you don't sacrifice patency of the access for it. It does add additional distal flow to the extremity.

It's definitely a more morbid procedure. It involves generally harvesting the saphenous vein from patients that may not be the best risk surgical patients, but again, it's a good choice for low flow fistula. RUDI, revision using distal inflow, is basically

a flow restrictive procedure just like banding. You're simply, it's a little bit more complicated 'cause you're usually doing a vein graft from the radial artery to the fistula. But it's less complicated than DRIL. Similar limitations to banding.

Very limited clinical data. There's really just a few series of fewer than a dozen patients each to go by. Finally, a proximalization of arterial inflow, in this case rather than ligating the brachial artery you're ligating the fistula and going to a more proximal

vessel that often will accommodate higher flow. In our hands, we were often talking about going to the infraclavicular axillary artery. So, it's definitely more morbid than a banding would be. This is a better choice though for prosthetic grafts that, where you want to preserve flow.

Again, data on this is very limited as well. The (mumbles) a couple years ago they asked the audience what they like and clearly DRIL has become the most popular choice at 60%, but about 20% of people were still going to banding, and so my charge was to say when is banding

the right way to go. Again, it's effect is less predictable than DRIL. You definitely are going to slow the flows down, but remember with DRIL you are making the limb dependent on the patency of that graft which is always something of concern in somebody

who you have caused an ischemic hand in the first place, and again, the morbidity with the DRIL certainly more so than with the band. We looked at our results a few years back and we identified 31 patients who had steal. Most of these, they all had a physiologic test

confirming the diagnosis. All had some degree of pain or numbness. Only three of these patients had gangrene or ulcers. So, a relatively small cohort of limb, of advanced steal. Most of our patients were autogenous access,

so ciminos and brachycephalic fistula, but there was a little bit of everything mixed in there. The mean age was 66. 80% were diabetic. Patients had their access in for about four and a half months on average at the time of treatment,

although about almost 40% were treated within three weeks of access placement. This is how we do the banding. We basically expose the arterial anastomosis and apply wet clips trying to get a diameter that is less than the brachial artery.

It's got to be smaller than the brachial artery to do anything, and we monitor either pulse volume recordings of the digits or doppler flow at the palm or arch and basically apply these clips along the length and restricting more and more until we get

a satisfactory signal or waveform. Once we've accomplished that, we then are satisfied with the degree of narrowing, we then put some mattress sutures in because these clips will fall off, and fix it in place.

And basically this is the result you get. You go from a fistula that has no flow restriction to one that has restriction as seen there. What were our results? Well, at follow up that was about almost 16 months we found 29 of the 31 patients had improvement,

immediate improvement. The two failures, one was ligated about 12 days later and another one underwent a DRIL a few months later. We had four occlusions in these patients over one to 18 months. Two of these were salvaged with other procedures.

We only had two late recurrences of steal in these patients and one of these was, recurred when he was sent to a radiologist and underwent a balloon angioplasty of the banding. And we had no other morbidity. So this is really a very simple procedure.

So, this is how it compares with DRIL. Most of the pooled data shows that DRIL is effective in 90 plus percent of the patients. Patency also in the 80 to 90% range. The DRIL is better for late, or more often used in late patients,

and banding used more in earlier patients. There's a bigger blood pressure change with DRIL than with banding. So you definitely get more bang for the buck with that. Just quickly going through the literature again. Ellen Dillava's group has published on this.

DRIL definitely is more accepted. These patients have very high mortality. At two years 50% are going to be dead. So you have to keep in mind that when you're deciding what to do. So, I choose banding when there's no gangrene,

when there's moderate not severe pain, and in patients with high morbidity. As promised here's an algorithm that's a little complicated looking, but that's what we go by. Again, thanks very much.

- We are talking about the current management of bleeding hemodialysis fistulas. I have no relevant disclosures. And as we can see there with bleeding fistulas, they can occur, you can imagine that the patient is getting access three times a week so ulcerations can't develop

and if they are not checked, the scab falls out and you get subsequent bleeding that can be fatal and lead to some significant morbidity. So fatal vascular access hemorrhage. What are the causes? So number one is thinking about

the excessive anticoagulation during dialysis, specifically Heparin during the dialysis circuit as well as with cumin and Xarelto. Intentional patient manipulati we always think of that when they move,

the needles can come out and then you get subsequent bleeding. But more specifically for us, we look at more the compromising integrity of the vascular access. Looking at stenosis, thrombosis, ulceration and infection. Ellingson and others in 2012 looked at the experience

in the US specifically in Maryland. Between the years of 2000/2006, they had a total of sixteen hundred roughly dialysis death, due to fatal vascular access hemorrhage, which only accounted for about .4% of all HD or hemodialysis death but the majority did come

from AV grafts less so from central venous catheters. But interestingly that around 78% really had this hemorrhage at home so it wasn't really done or they had experienced this at the dialysis centers. At the New Zealand experience and Australia, they had over a 14 year period which

they reviewed their fatal vascular access hemorrhage and what was interesting to see that around four weeks there was an inciting infection preceding the actual event. That was more than half the patients there. There was some other patients who had decoags and revisional surgery prior to the inciting event.

So can the access be salvaged. Well, the first thing obviously is direct pressure. Try to avoid tourniquet specifically for the patients at home. If they are in the emergency department, there is obviously something that can be done.

Just to decrease the morbidity that might be associated with potential limb loss. Suture repairs is kind of the main stay when you have a patient in the emergency department. And then depending on that, you decide to go to the operating room.

Perera and others 2013 and this is an emergency department review and emergency medicine, they use cyanoacrylate to control the bleeding for very small ulcerations. They had around 10 patients and they said that they had pretty good results.

But they did not look at the long term patency of these fistulas or recurrence. An interesting way to kind of manage an ulcerated bleeding fistula is the Limberg skin flap by Pirozzi and others in 2013 where they used an adjacent skin flap, a rhomboid skin flap

and they would get that approximal distal vascular control, rotate the flap over the ulcerated lesion after excising and repairing the venotomy and doing the closure. This was limited to only ulcerations that were less than 20mm.

When you look at the results, they have around 25 AV fistulas, around 15 AV grafts. The majority of the patients were treated with percutaneous angioplasty at least within a week of surgery. Within a month, their primary patency was running 96% for those fistulas and around 80% for AV grafts.

If you look at the six months patency, 76% were still opened and the fistula group and around 40% in the AV grafts. But interesting, you would think that rotating an adjacent skin flap may lead to necrosis but they had very little necrosis

of those flaps. Inui and others at the UC San Diego looked at their experience at dialysis access hemorrhage, they had a total 26 patients, interesting the majority of those patients were AV grafts patients that had either bovine graft

or PTFE and then aneurysmal fistulas being the rest. 18 were actually seen in the ED with active bleeding and were suture control. A minor amount of patients that did require tourniquet for a shock. This is kind of the algorithm when they look at

how they approach it, you know, obviously secure your proximal di they would do a Duplex ultrasound in the OR to assess hat type of procedure

they were going to do. You know, there were inciting events were always infection so they were very concerned by that. And they would obviously excise out the skin lesion and if they needed interposition graft replacement they would use a Rifampin soak PTFE

as well as Acuseal for immediate cannulation. Irrigation of the infected site were also done and using an impregnated antibiotic Vitagel was also done for the PTFE grafts. They were really successful in salvaging these fistulas and grafts at 85% success rate with 19 interposition

a patency was around 14 months for these patients. At UCS, my kind of approach to dealing with these ulcerated fistulas. Specifically if they bleed is to use

the bovine carotid artery graft. There's a paper that'll be coming out next month in JVS, but we looked at just in general our experience with aneurysmal and primary fistula creation with an AV with the carotid graft and we tried to approach these with early access so imagine with

a bleeding patient, you try to avoid using catheter if possible and placing the Artegraft gives us an opportunity to do that and with our data, there was no significant difference in the patency between early access and the standardized view of ten days on the Artegraft.

Prevention of the Fatal Vascular Access Hemorrhages. Important physical exam on a routine basis by the dialysis centers is imperative. If there is any scabbing or frank infection they should notify the surgeon immediately. Button Hole technique should be abandoned

even though it might be easier for the patient and decreased pain, it does increase infection because of that tract The rope ladder technique is more preferred way to avoid this. In the KDOQI guidelines of how else can we prevent this,

well, we know that aneurysmal fistulas can ulcerate so we look for any skin that might be compromised, we look for any risk of rupture of these aneurysms which rarely occur but it still needs to taken care of. Pseudoaneurysms we look at the diameter if it's twice the area of the graft.

If there is any difficulty in achieving hemostasis and then any obviously spontaneous bleeding from the sites. And the endovascular approach would be to put a stent graft across the pseudoaneurysms. Shah and others in 2012 had 100% immediate technical success They were able to have immediate access to the fistula

but they did have around 18.5% failure rate due to infection and thrombosis. So in conclusion, bleeding to hemodialysis access is rarely fatal but there are various ways to salvage this and we tried to keep the access viable for these patients.

Prevention is vital and educating our patients and dialysis centers is key. Thank you.

- I think by definition this whole session today has been about challenging vascular access cases. Here's my disclosures. I went into vascular surgery, I think I made the decision when I was either a fourth year medical student or early on in internship because

what intrigued me the most was that it seemed like vascular surgeons were only limited by their imagination in what we could do to help our patients and I think these access challenges are perfect examples of this. There's going to be a couple talks coming up

about central vein occlusion so I won't be really touching on that. I just have a couple of examples of what I consider challenging cases. So where do the challenges exist? Well, first, in creating an access,

we may have a challenge in trying to figure out what's going to be the best new access for a patient who's not ever had one. Then we are frequently faced with challenges of re-establishing an AV fistula or an AV graft for a patient.

This may be for someone who's had a complication requiring removal of their access, or the patient who was fortunate to get a transplant but then ended up with a transplant rejection and now you need to re-establish access. There's definitely a lot of clinical challenges

maintaining access: Treating anastomotic lesions, cannulation zone lesions, and venous outflow pathology. And we just heard a nice presentation about some of the complications of bleeding, infection, and ischemia. So I'll just start with a case of a patient

who needed to establish access. So this is a 37-year-old African-American female. She's got oxygen-dependent COPD and she's still smoking. Her BMI is 37, she's left handed, she has diabetes, and she has lupus. Her access to date - now she's been on hemodialysis

for six months, all through multiple tunneled catheters that have been repeatedly having to be removed for infection and she was actually transferred from one of our more rural hospitals into town because she had a infected tunneled dialysis catheter in her femoral region.

She had been deemed a very poor candidate for an AV fistula or AV graft because of small veins. So the challenges - she is morbidly obese, she needs immediate access, and she has suboptimal anatomy. So our plan, again, she's left handed. We decided to do a right upper extremity graft

but the plan was to first explore her axillary vein and do a venogram. So in doing that, we explored her axillary vein, did a venogram, and you can see she's got fairly extensive central vein disease already. Now, she had had multiple catheters.

So this is a venogram through a 5-French sheath in the brachial vein in the axilla, showing a diffusely diseased central vein. So at this point, the decision was made to go ahead and angioplasty the vein with a 9-millimeter balloon through a 9-French sheath.

And we got a pretty reasonable result to create venous outflow for our planned graft. You can see in the image there, for my venous outflow I've placed a Gore Hybrid graft and extended that with a Viabahn to help support the central vein disease. And now to try and get rid of her catheters,

we went ahead and did a tapered 4-7 Acuseal graft connected to the brachial artery in the axilla. And we chose the taper mostly because, as you can see, she has a pretty small high brachial artery in her axilla. And then we connected the Acuseal graft to the other end of the Gore Hybrid graft,

so at least in the cannulation zone we have an immediate cannualation graft. And this is the venous limb of the graft connected into the Gore hybrid graft, which then communicates directly into the axillary vein and brachiocephalic vein.

So we were able to establish a graft for this patient that could be used immediately, get rid of her tunneled catheter. Again, the challenges were she's morbidly obese, she needs immediate access, and she has suboptimal anatomy, and the solution was a right upper arm loop AV graft

with an early cannulation segment to immediately get rid of her tunneled catheter. Then we used the Gore Hybrid graft with the 9-millimeter nitinol-reinforced segment to help deal with the preexisting venous outflow disease that she had, and we were able to keep this patient

free of a catheter with a functioning access for about 13 months. So here's another case. This is in a steal patient, so I think it's incredibly important that every patient that presents with access-induced ischemia to have a complete angiogram

of the extremity to make sure they don't have occult inflow disease, which we occasionally see. So this patient had a functioning upper arm graft and developed pretty severe ischemic pain in her hand. So you can see, here's the graft, venous outflow, and she actually has,

for the steal patients we see, she actually had pretty decent flow down her brachial artery and radial and ulnar artery even into the hand, even with the graft patent, which is usually not the case. In fact, we really challenged the diagnosis of ischemia for quite some time, but the pressures that she had,

her digital-brachial index was less than 0.5. So we went ahead and did a drill. We've tried to eliminate the morbidity of the drill bit - so we now do 100% of our drills when we're going to use saphenous vein with endoscopic vein harvest, which it's basically an outpatient procedure now,

and we've had very good success. And here you can see the completion angiogram and just the difference in her hand perfusion. And then the final case, this is a patient that got an AV graft created at the access center by an interventional nephrologist,

and in the ensuing seven months was treated seven different times for problems, showed up at my office with a cold blue hand. When we duplexed her, we couldn't see any flow beyond the AV graft anastomosis. So I chose to do a transfemoral arteriogram

and what you can see here, she's got a completely dissected subclavian axillary artery, and this goes all the way into her arterial anastomosis. So this is all completely dissected from one of her interventions at the access center. And this is the kind of case that reminded me

of one of my mentors, Roger Gregory. He used to say, "I don't wan "I just want out of the trap." So what we ended up doing was, I actually couldn't get into the true lumen from antegrade, so I retrograde accessed

her brachial artery and was able to just re-establish flow all the way down. I ended up intentionally covering the entry into her AV graft to get that out of the circuit and just recover her hand, and she's actually been catheter-dependent ever since

because she really didn't want to take any more chances. Thank you very much.

- I'm going to be speaking about indirect access sites for access intervention. I'm going to be focusing on the transjugular approach. So access interventions, typically we perform them through a direct puncture of the fistula. Sometimes you place two introducers. There are some disadvantages to the direct approach.

The crossing catheters technique that we generally use for declots is awkward and cumbersome. The introducers can obstruct flow, there's dead space behind the introducers that can trap clot, and there's radiation exposure or the direct exposure

or scatter radiation from hands near the field. Admit it, we've all had access-site complications, suture-site necrosis and infection, as well as pseudoaneurysms. There's also prolonged procedure time related to needing to obtain hemostasis

in the high-pressure segment. There are also problems particularly to immature fistulas, such as hematoma formation, spasm at the introducer site causing pseudo-stenosis, decreased flow, and fistula thrombosis. Now, the good news is that we do have options

for alternative access sites. I'm sure many of you here use arterial access for immature fistulas in particular. Brachial access can be used to, this can be used for diagnostic or therapeutic purposes. We can also utilize radial or ulnar access.

Rarely, femoral access is used, as we saw in the last presentation. But there's also pendula venous access sites. You can sometimes, as a fortuitous tributary, what I call a target of opportunity, and also, the internal jugular vein.

Now, the transjugular approach was first reported in 1998. It does have some definite advantages over direct puncture technique. You can avoid the cumbersome access, you can keep your hands away from the beam, and there's no dead space as compared

to crossing sheaths for your declot. And if the intervention is unsuccessful, you can convert your IJ access to a catheter if you already have a wire in it. There are some technical challenges associated with this technique.

You do have to overcome the valves. It can be difficult to access the cephalic vein, but you can get around this by using a snare. And there's possibly a risk of IJ thrombosis if you're using large introducers. When to use this technique?

Well, when direct puncture's going to be difficult or cumbersome, when there's a short cannulation segment, when it's an extensively stented access, and when there's inflow pathology requiring a retrograde approach or arterial empathalogy, and it's a good option for clotted access.

The technique, micropuncture access of the jugular vein, ipsilateral or contralateral, place a sheath, and an important thing to use is a reverse-curve catheter, followed by glidewire. So here, we've cannulated the jugular vein going down,

glidewire out into the arm. If you're unable to cross into the cephalic vein, you can use that snare technique. And you can get a long, stable access in this way. It's been reported about, there's about 10 publications on transjugular approach, seven retrospective studies.

There's a large study that's reported thrombectomy. Also a large study looking at immature fistulas. Smaller studies looking at dysfunctional access and pseudoaneurysms. Two case reports, one review article, but there's of course no randomized studies.

There's a recent study from this year from Ferral and Alonzo. This was a retrospective study. Over two years they performed 30 transjugular AV access interventions. This accounted for 5% of their access experience

and this series was all fistulance. Indications for the procedure, 43% were declots, 43% were arterial and fistual pathology, there were two immature fistulas and two bleeding pseudoaneurysms. The access approach was 29 for ipsilateral,

only one contralateral. The results, 97% technical success, a snare was required in 4 cases, a catheter was inserted in two of the cases. There were no episodes of jugular vein thrombosis. In the remaining time, I'd like to show

a couple of case studies. Again, from Ferral and Alonzo. This is a case of an immature fistula. This was a partially occluded, immature left upper arm fistula. The initial fistulagram shows outflow stenosis

with a multiple stenosis in thrombus, and there's an arterial in stenosis that's distal to the access point, so you're not going to be able to treat that. They performed four millimeter angioplasty. Follow-up fistulagram shows a small, but patent vein

and the arterial end could not be treated. They brought the patient back in two weeks for a staged transjugular approach. And you can see the jugular catheter coming down. The vein diameter's improved, but there's still the untreated arterial end stenosis,

which is easily treated through the jugular approach. This is a study from, a case from Dr. Rabellino, ruptured pseudoaneurysm. This is a basilic transposition with a ruptured pseudoaneurysm at an infiltration site. Pretty ugly arm, swollen, skin necrosis.

I don't think we want to be sticking that arm. They initially went with a femoral approach for the fistulagram, demonstrated the pseudoaneurysm. As you can see here, tandem outflow stenoses. Coming up from below with the femoral artery diagnostic catheter.

Down and into the arm through the jugular approach. And here, you can see the venous outflow after angioplasty, covered stent deployed through the jugular access. So in summary, the transjugular approach is a useful but underutilized technique. The advantages include single-puncture intervention,

does not involve the outflow vein directly, simplified hemostasis, it's a low pressure system. It does have the advantage that you can use large introducers, there's less radiation for the operator, and you can convert to a catheter easily if needed. It is a useful technique for fistula maturation,

thrombectomy, and access maintenance. I say go for the jugular.

- Thank you so much. We have no disclosures. So I think everybody would agree that the transposed basilic vein fistula is one of the most important fistulas that we currently operate with. There are many technical considerations

related to the fistula. One is whether to do one or two stage. Your local criteria may define how you do this, but, and some may do it arbitrarily. But some people would suggest that anything less than 4 mm would be a two stage,

and any one greater than 4 mm may be a one stage. The option of harvesting can be open or endovascular. The option of gaining a suitable access site can be transposition or superficialization. And the final arterial anastomosis, if you're not superficializing can either be

a new arterial anastomosis or a venovenous anastomosis. For the purposes of this talk, transposition is the dissection, transection and re tunneling of the basilic vein to the superior aspect of the arm, either as a primary or staged procedure. Superficialization is the dissection and elevation

of the basilic vein to the superior aspect of the upper arm, which may be done primarily, but most commonly is done as a staged procedure. The natural history of basilic veins with regard to nontransposed veins is very successful. And this more recent article would suggest

as you can see from the upper bands in both grafts that either transposed or non-transposed is superior to grafts in current environment. When one looks at two-stage basilic veins, they appear to be more durable and cost-effective than one-stage procedures with significantly higher

patency rates and lower rates of failure along comparable risk stratified groups from an article from the Journal of Vascular Surgery. Meta-ana, there are several meta-analysis and this one shows that between one and two stages there is really no difference in the failure and the patency rates.

The second one would suggest there is no overall difference in maturation rate, or in postoperative complication rates. With the patency rates primary assisted or secondary comparable in the majority of the papers published. And the very last one, again based on the data from the first two, also suggests there is evidence

that two stage basilic vein fistulas have higher maturation rates compared to the single stage. But I think that's probably true if one really realizes that the first stage may eliminate a lot of the poor biology that may have interfered with the one stage. But what we're really talking about is superficialization

versus transposition, which is the most favorite method. Or is there a favorite method? The early data has always suggested that transposition was superior, both in primary and in secondary patency, compared to superficialization. However, the data is contrary, as one can see,

in this paper, which showed the reverse, which is that superficialization is much superior to transposition, and in the primary patency range quite significantly. This paper reverses that theme again. So for each year that you go to the Journal of Vascular Surgery,

one gets a different data set that comes out. The final paper that was published recently at the Eastern Vascular suggested strongly that the second stage does consume more resources, when one does transposition versus superficialization. But more interestingly also found that these patients

who had the transposition had a greater high-grade re-stenosis problem at the venovenous or the veno-arterial anastomosis. Another point that they did make was that superficialization appeared to lead to faster maturation, compared to the transposition and thus they favored

superficialization over transposition. If one was to do a very rough meta-analysis and take the range of primary patencies and accumulative patencies from those papers that compare the two techniques that I've just described. Superficialization at about 12 months

for its primary patency will run about 57% range, 50-60 and transposition 53%, with a range of 49-80. So in the range of transposition area, there is a lot of people that may not be a well matched population, which may make meta-analysis in this area somewhat questionable.

But, if you get good results, you get good results. The cumulative patency, however, comes out to be closer in both groups at 78% for superficialization and 80% for transposition. So basilic vein transposition is a successful configuration. One or two stage procedures appear

to carry equally successful outcomes when appropriate selection criteria are used and the one the surgeon is most favored to use and is comfortable with. Primary patency of superficialization despite some papers, if one looks across the entire literature is equivalent to transposition.

Cumulative patency of superficialization is equivalent to transposition. And there is, appears to be no apparent difference in complications, maturation, or access duration. Thank you so much.

- So, I'm going to be talking about options in patients with bilateral brachiocephalic vein occlusion. There's a recent reporting standards on this that's been published by the Society for Interventional Radiology, and one of the things they ask us,

is to use brachiocephalic instead of innominate, so I'm going to be a nice team player, and say brachiocephalic. So again I have no conflicts if interest relative to this. What's the problem with brachiocephalic vein inclusion? Well obviously venous outflow to the heart is obstructed.

And as I said, the recent classification scheme is just coming out, and I actually haven't gotten my hands on it, so I believe it's class 3 or type 3, but I can't answer that as yet. And we've all been in this situation,

and I'm going to extend my concept of brachiocephalic vein inclusion, to include the subclavian vein. In my opinion, you know these are multifactorial a lot of these are from improperly placed catheters, but we haven't been doing subclavian catheters

for a decade now, and this problem isn't going away you know a lot of it is the venous form of thoracic outlet syndrome, which then progresses centrally. So what's our algorithm? You know there's no answer,

these are a protean group of people, and there's no obvious answer here. My viewpoint, and I think it's pretty reasonable, step one, obviously is the access worth saving. We just shot a picture there, the jugular vein approach on that blown out arm,

I wouldn't have tried to save that access, I think I would've given up the ghost on that one. So congratulations on saving it. So, you got to look at the quality of the access, how good is it, the degree of symptoms the patients having, how much swelling, general age, health,

and obviously life expectancy of the patient, multiple other options. So really don't just automatically say you got to fix that brachiocephalic vein, you got to first say, well is the access worth saving or not. So that the technical talk,

is today is bilateral brachiocephalic occlusion, and thus by definition, the other side aint going to be any better. So if you're going to get rid of this access you got to think about, well how are you going to get access to this person?

If you've got bilateral occlusion, things aren't really better. And really if you're dealing with this kind of situation, if you're not going to sort of try and open this up again, really a leg, a leg access, or some sort of exotic venous outflow into the atrium,

which we'll talk about right at the end etc. Is really your only other option. So number one, is it worth saving. You know leg is not a bad option. In the old days, this was associated with a very high infection rate,

disproportionate morbidity and mortality. I did a bunch of maybe 10 leg AV fistulas, using the femoral vein, and I would quote the patient wound complication rate of right around 100% give or take nothing. And we had a limb loss rate,

in the 10 patients or 12 patients that I did, we had a limb loss rate within a few years of 25%. So, absolutely not a benign procedure, the fistula. Today, people are moving more and more toward leg graphs, and the interesting thing is, and as vascular surgeons,

we live in the common femoral artery and vein, we're really basing these now off the superficial femoral system, and we're staying out of the groin, the skin is a little bit less dirty down there, we're not into the lymph node basin,

and the results empirically seem to be pretty good, and quite interestingly patient satisfaction seems fairly high. So, this is sort of an example of what we're talking about, superficial femoral vessels, at least to the right of the screen.

So option number one, ligate the access in your arm, place thigh access. Number two, step number two, if the access is worth saving, can you recanalize the brachiocephalic, not really so straightforward. You need access from above and below,

you need sophisticated imaging, pre- and intraop, specialized tools, we have a steerable sheath, multiple wire options, snares, you need bailout options, covered stents. If you rupture something, I didn't put it on the slide, but I think you need also interventionalists in surgeons,

you know it can be the same person, but you really need both interventional skills, and surgical skills both. You need experience, you need a certain amount of courage, and you definitely need malpractice insurance. Definitely beware the SVC/atrial junction.

John Ross, has had two terrible ruptures, which he shown at various meetings, both were laid at a seemingly innocuous 8 mm balloon angioplasty in this area. So successful recanalizaton, you got to wire through, you're probably going to have a stent,

and that stents probably going to go through the costoclavicular junction. And I hate to be a broken record, here's the vein in the clavicle, you put a stent through there and now you got to get, now it's the wrath of Karl.

So, you got to get that rib out there. It may be covered stents, it may work better in this situation an may be a little bit more resistant to rupture or anything like that, we really don't know.

So option number one, is ligate the access, place thigh. Number two, is recanalize, put a stent through there, remove the rib. Inside out technique is a pretty nice thing, relies on the fact that the veins are anterior to everything else,

including the arteries and the brachial plexus, which is ignored a little bit. You can do this homemade, with a steerable sheath and the back end of a wire. As surgeons we can make a little bitty cut down, and grab that wire if you can get anywhere within about

two or 3 cm of the skin. Now there's a commercial product, which is in trials, variously called Bluegrass or Surfacer, which kind of allows you to do this sort of all in one piece, so it's pretty nice. Best option, I am increasingly feel,

we've done several of these going right to a HeRo, there was a little bit of data presented at VASA a little while ago, I think my Jeff Lawson saying, that "If you do it in stages, "the infection rate is actually lower", which seems a little bit counter intuitive,

but there all psychological benefits in just getting your catheter in there first, stepping back, taking a deep breath, bringing the guy back in a few weeks, and convert it to a HeRo. Number three, number three is inside out to HeRo.

How about another option, really good risk patient, long life expectancy, consider direct surgical reconstruction. And the reconstruction components pretty easy, it's the exposure that's tough, you can do a claviculectomy, you can do a Molina procedure,

a first interspace sternotomy, rotate everything up. This you really need a thoracic outlet surgeon or somebody experienced in this area. You can also do subclavian to atrial appendage bypass, it does not require sternotomy, but you do it through a third interspace pericardotomy.

Published N is only probably about 20 patients, long-term outcome unknown, and this is really what you got. So you got lots of options, the bottom line, think long and hard as to whether or not the access is worth saving, if it's not, modern techniques for AV thigh grafts

are actually much better than you would think. And if it is, then either get through with a wire, decompress that thoracic outlet, or you can attack the problem directly. Thank you very much.

- Thank you for asking me to speak. I'm going to touch on a couple of topics that Dr. El Legari spoke about and give some more information. I have no disclosures. Again, we're talking about central venous anatomy. So we're talking about specifically is occlusions

of the innominate or brachial cephalic bilaterally and the superior vena cava. This is a typical venogram of these types of patients. You see a dilated subclavian or internal jugular veins that usually lead to occlusions, large collateral networks,

and usually a smattering of occluded stents. The first report of a subclavian vein to right atrial bypass was by Denton Cooley in 1991. In 1999, El-Sahrout looked to describe this technique in nine patients. And noted that eight of the nine patients

had a significant resolution of their symptoms using this technique and no peri-operative mortality. Long-term outcomes were tracked for 53 months. Six of the patient bypasses continued to be patent with complete relief of symptoms. One had recurring edema 38 months out and

two patients needed an AV access removal at four and a half and six months for infection. There were seven deaths during the follow-up period. So what happened is, it seems like a good operation. Why hasn't it really taken off?

I think the biggest issue is as well been talking about, we're concerned that these patients that are medically unfit for large open surgery, particularly median sternotomy. Also, endovascular techniques have been developed. The HeRO graft was released.

We've come up with alternative options for access including lower extremity AV access, catheter dependence, switching the peritoneal dialysis and the lucky patients get kidney transplants. Looking at long-term outcomes of some of these various other techniques is actually like

getting head touched behind. Looking at endovascular techniques, particularly for central venous occlusions of the brachial, cephalic and superior vena cava. The results aren't nearly as good as looking at more proximal occlusions.

Bacon looked at 47 patients with 49 central angioplasties and 26 central stents. Outcomes at 30 days weren't bad at 76 percent. The twelve months dropped to 29 percent for angioplasty alone and 21 percent for stenting. Primary assisted patency was better at 73 percent.

For angioplasty, an 84 percent for stenting. However, this required on average, two to three extra procedures to maintain that primary patency. Looking at HeRO grafts, again particularly essentially for venous stenosis. Wallace looked at 21 patients that had

21 attempted placements in 19 patients and had an 86 percent successful placement. However, again outcomes at 12 months was low as 11 percent for primary patency and 32 percent for secondary patency, with an average of four thrombectomies

to keep that patency right. I do agree it does appear that lower extremity access is probably the best option when having central venous stenosis. Here, Stearman looked at HeRO grafts versus lower extremity AV access and noted

that the 22 patients undergoing lower extremity AV access had a 77 percent secondary patency rate at six months only required one extra procedure to keep this. So looking at all that, right atrial bypass may still be, should still be considered

an option in these types of patients. If you look at the DOQI guidelines, they actually recommend after endovascular techniques have failed, that we should be considering a surgical option for central venous stenosis. Some technical tips on how to perform

t inflow must be very clearly evaluated. The patient should have venogram and most commonly, the inflow can be taken from the infraclavicular axillary vein with an

end to sided anastamosis to a PTFE graft. The best conduit for use is a ten to sixteen millimeter external reinforced PTFE graft. A tunnel may be made bluntly through the second intercostal space. Usually we do use a median steronomy

to get the outflow. And you can see right here, you can sew directly end to end to the atrial, right atrial appendage. I think the most important thing to understand when you're doing these bypasses is you need

to keep a patent AV access in the arm to keep the bypass open. If the patients have a thrombosed access, you can attempt thrombectomy at that time. If an access is not salvageable, you should place a new access at that time to keep the

right atrial bypass open. Some precautions. As always the best precaution is prevention. You should avoid central venous catheters. Autogenous AV access is obviously the best for as long as patency rates.

Should avoid central venous stents, if at all possible. And patients should be referred early for transplants. If you're unable to prevent it, patient selection for this operation is critical.

We have to look at patients that are younger, and felt to be more fit to undergo a large operation. Usually, after the failed multiple endovascular procedures, we should be thinking about this operation. In particular, in patients that aren't

good candidates for lower extremity AV access due to peripheral vascular disease or peritoneal dialysis due to history of many abdominal surgeries or peritonitis. And again we should also always be thinking about this operation in patients that are not

good candidates or do not have kidney donors available. Thank you very much.

- [Female Audience Member] For the fatal vascular access bleed, there's actually a brand new tool that just came out by the British Renal Society. You can get it at the website, it's britishrenal.org and it's actually a green, yellow, red tool for the dialysis staff, like the one minute check

to assess the access site if it is at risk for fatal vascular access hemorrhage. So I recommend, along with getting all the fistula first tools, that you guys please get that, because what you pointed out fatal vascular access hemorrhage does happen.

I've seen it, and it's extremely scary when it happens for patients, and keep in mind it does mainly happen at home. So the patients must be taught what to do should they have it, and those tools are included in that new kit.

- Thank you, that's great. - Dr. Shenoy misses being on the podium. - [Male Audience Member] I just want to follow up-- - You can come up here and join us if you want to. - [Male Audience Member] I just wanted to follow up on what Debbie said.

One other thing we could do for the patients, which I always do when I consider patients who may be at risk regarding aneurysmal access, is to show them where the end flow is, and show them how to occlude the inflow and lift the arm up, access completely disappears.

And that's the best way, I've had at least several patients do that, call 911, and land up safely in the hospital with the bleed. So teaching the patient how to occlude the inflow is the most important thing. Because if you get flustered when you have a bleed,

like many of our residents do when they see a bleed they try to stop the bleed and you can't. You stop the inflow and the bleed stops. So that's probably easy thing to do, to teach the patient and I do it all the time.

About the tie fistulas, I've had a different experience with tie fistula, but I think case selection is very important and tie fistulas, if we can get them going, they do extremely well, and they're at the very low risk.

I have not had the experience which you had where there are 25 percent issues with the thing. - And I've tried everything. I've tried skin bridges, and not ligating any little branches, I tried freakin' everything, and every single one of them

had some sort of wound complication. It wasn't an infection, per se, but just healing that wound. I agree, they're great. It's a great fistula, and it's fun surgery if you've got-- - What do people use for a conduit for leg graphs? I've had some real bad seromas with conventional PTFE.

Use autographed, yeah? That's what I've been using. (audience member mumbling) - But with regard to the bleeds, I will tell you that the college is pushing the Stop the Bleed campaign

and will provide Tourniquets free within the United States, and so people can come to your dialysis center and actually teach people how to stop the bleed. They just have to go upwards, not downwards. But that's now available, and free for everybody.

So it was initially started as a mass casualty within the US military but it's now available and being pushed by the surgical and other emergency medicine societies. So you may want to avail of that free asset within the United States.

- We give all our patients stethoscopes. Here's a stethoscope, here's a rubber ball and here's a tourniquet. (audience laughing) - David. - I just had one question, the comment regarding

cryo-preserved vein for the thigh graft. We put in 25 of those and published in the Journal of Vascular Surgery that a word of caution in the thigh. We had about 50 percent of those blew out from needle puncture sites.

And so I just throw that out. I had two questions regarding the treatment of the cephalic arch stenosis. I like the turndown, it's an elegant operation, but I've wondered. You're kind of violating another

potential access territory and I'm wondering if its better to intervene on the cephalic arch endovascularly and preserve that basilic axillary segment for perhaps a basilic vein, a new access all together. And my second, I just throw that out.

I've always been concerned when I've done the turndown procedure with regards to that. And the other is I've never done this but I wonder, has anybody tried to directly attack the cephalic arch stenosis?

Is it accessible for direct angioplasty. I mean... a vein patch. - So we usually do one angioplasty and make a decision. If the fistula is a good fistula and hasn't been re-intervened on

I think it's worthwhile doing a turndown. If it's a fistula that's somewhat dicey I think doing a turndown is the wrong place to go. And then you should really sort of do some kind of frailty index or equivalent on your patient. And they may benefit more from a stemmed graft

rather than from doing the actual procedure. The procedure itself you can do with a block and open anesthetic. One teaching point is for the people, not to ain for the basilic vein but to actually aim for the auxiliary vein.

So that you at least preserve one other. There is, I think, like five descriptions of patch angioplasty of the cephalic vein. That's out in the literature, but they are individual case reports. - Question?

- [Audience Member] Yeah, quick question. This is regarding steal syndromes. You have radiocephalic and brachiocephalic. So in some of the radiocephalic, if you do angiography, it's a good reversal of flow. So we have embolized distal radial artery in many instances

wherein you find the patient has significant improvement. With respect to brachiocephalic, I do an angiogram and you could clearly see that hardly any flow to the distal brachial or radial artery. And then you put either a nine or a seven French sheath

and just lag it over it. And repeat the study, you'll see distinctly, pretty decent flow in most of the cases. - I have used the embolization for the rare cases of steal that you see with Cimino fistula which is very uncommon, to get it in the first place.

To me I don't think the artery knows whether it's brachial or a radial artery. All it knows is what size it is, what diameter it is and that's what, to the fourth power, is going to set the resistance of it. So I've just always found it simpler to

simply tailor the stenosis to what gives you good affect. - And Matt, just going to ask you a follow up question. How do you know when to stop when you do the bending? Do you do an intraoperative monitoring such as digital flow or anything like this to determine when to stop?

- We tried a PVR cusp but couldn't keep them sterilely. They didn't hold up well. But I think that's the best way. We used doppler interrogation of the pomeral arch. But I think your point is well taken. It's one thing to say it seems fine now

while they're under anesthesia, whatever their blood pressure is. They're not on dialysis right now so. I'd band it as much as you possibly can and still have a thrill at the end. - Tony, just to add to that.

Despite my predilection for drill, when we do do banding we actually us intropeter flow monitoring. So we put a flow catheter in the access. We measure it's baseline flow and we make sure that if it's graft

we're going to try and stay above that 600 threshold while we're banding it. - Another way of doing it, I do a transfemoral angiogram and park a catheter in the subclavian artery and then I'll repetitively band down around a sheath,

smaller and smaller and smaller until I start to see good flow into the forearm. Having said that, every single time I end up with a seven sheath. So I think I've kind of abandoned that now and I think I just use a seven sheath.

And again, empirically, Greg Miller really has shown that about a three millimeter balloon seems to be about right. - Based upon what little consensus there is on all of this? - What? - It's amazing how little consensus there is

on all these management issues. - Well I think the consensus is you can't just blindly band. You've got to band to some sort of physiologic or relevant anatomic technique. - Robin, have you considered when you do the

atrial grafts in order to keep that appendage area open use PTFE graft with rings is to keep one of the rings at the end and incorporate the ring in the anastomosis. - Right, exactly, that's how we do it. - Another question? - Yeah, I'm Pablo Uceda from Dallas.

Question for Doctor Illik. I see the meeting in Austin in 2016. A Doctor Hall from Richmond, Virginia described an axillary to numbing it. Of subclavian endovascular bypass using a viabahn graft. I haven't heard anything else.

He did send me his technique. But I never attempted it. The second question is I think we talked about this over the phone a couple of months ago.

About the viabahn gore. Send me an email of an intervention of radiologists that treats Thoracic Outlet Syndrome endovascularly with a long 12 or 14 viabahn,

endograph and I wanted your opinions about that, thank you. - So yeah, and that's actually, I had mentioned that at the podium related to that conversation so I'm glad you brought it up again. To my knowledge, there are no data yet

but there are several people roaming around who have at least seemed to get good results with a covered stent. Gore viabahn is obviously a great option but a covered stent through the thoracic outlet. And I'm not to the point of being

a traitor to my TOS roots yet but I think this is something that should be looked at. The bad news about a stent is it gets fractured, the metal gets fractured by the bones. But if you've got a covered stent in there with better external and internal

continuity, whatever, may be better. So I think in the absence of data I'm still going to advocate taking out the ribs but I think this is an interesting concept that we should follow over the next few years.

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