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Presentation for: Tri-Service General Hospital July 22nd, 2008. Flow-Based Vascular Access Management. A Quantitative approach to preserving access patency; A patient’s link to life. Flow-Based. Surgical Creation of the access Hemodialysis Surveillance Angioplasty or

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Presentation for:

Tri-Service General Hospital

July 22nd, 2008


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Flow-BasedVascular Access Management

A Quantitative approach to preserving access patency;

A patient’s link to life


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Flow-Based

  • Surgical Creation

  • of the access

  • Hemodialysis

  • Surveillance

  • Angioplasty or

  • Surgical Revision


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Vascular Access Management Tools

Intraoperative Flowmeter

Endovascular Flowmeter

Hemodialysis Monitor



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HT300-Series Flowmeters

  • Mean Volume Flow Digital Display

  • Wave-Form printer

  • FlowSound

  • Inversion button (+/-)

Above - HT313 , Below -HT323


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Transonic (FMV) Vascular Flowprobes

  • Available in a wide range of sizes (1.5 to 14 mm)

  • Reusable

  • Steam, EtO and Sterrad Sterilizable



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TTU

Difference between T-1 and T-2 is a phase change proportional to volume Flow


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ValidationTransit-Time Ultrasound

(r = 0.93–0.95) 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 2000;70:212–217.


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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 (Don’t Twist)


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Movies (If available)

Applying Gel

Applying Flowprobe to Vessel

Flowsound

Documenting Waveform


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End-to-side anastomosis

Measure Venous Outflow


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Side-to-Side Anastomosis

Measure Venous Outflow


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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):729–738, 1998.


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Fistula Flow Patency Results

Johnson, CP et al, “Prognostic Value of Intraoperative Blood flow Measurements in Vascular Access Surgery,” Surgery 124(4) 729–738, 1998.


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AV Fistula Guidelines

Johnson, CP et al, “Prognostic Value of Intraoperative Blood flow Measurements

in Vascular Access Surgery,” Surgery 124(4):729–738, 1998.


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Clinical Results - Fistula

  • Berman72 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.


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Fistula Guidelines

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.


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PTFE Grafts

Air in the graft interstices block ultrasound transmission.

Therefore, measure at the distal outflow of the graft.


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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):729–738, 1998.


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PTFE Graft Flow Guidelines cont.

Johnson, CP et al, “Prognostic Value of Intraoperative Blood flow Measurements

in Vascular Access Surgery,” Surgery 124(4):729–738, 1998.


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Flow-QC Measurements

  • Quick, accurate, and easy to perform

  • May indicate corrections during surgery

  • Can predict the ultimate survival of an AV access


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Flow-based Surveillance

during Hemodialysis


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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/guideline_upHD_PD_VA/index.htm


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K/DOQI Goal:

  • Detect access dysfunction prior to access thrombosis.

http://www.kidney.org/PROFESSIONALS/kdoqi/guideline_upHD_PD_VA/va_guide4.htm


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K/DOQI Suggested Technology

  • Indicator dilution (Transonic) flow measurements are the preferred method of A-V graft and fistula surveillance.



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Transonic Flow-QC® Hemodialysis Monitor

The Standard of Care for the ESRD patient


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HD Monitor Parameters

  • Dialysis Adequacy

    • Delivered Blood Flow

    • Recirculation

  • Vascular Access Flow

  • Cardiac Output


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Access Flow Measurement (Blood Lines are Reversed)



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K/DOQI Guidelines for Monitoring AV Grafts and Fistulas

  • Access flow < 600 ml/min, the patient should be referred for fistulagram.

  • Access flow < 1000ml/min that has decreased by > 25% over 4 months should be referred for fistulagram.


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Monthly Access Flow Trending

K/DOQI Guideline: <600 ml/min

Documented Intervention


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Clinical Results

  • Gambro Study

  • McCarley Study


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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.


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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


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Three-Phase Study Morbidity and Costs

132 Hemodialysis Patients with A-V grafts or fistulas.


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Europe Morbidity and Costs

  • “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


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Japan Morbidity and Costs

  • “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


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Flow-QC in HD Morbidity and Costs

Preserve an Access - Save a Live


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Flow-based Morbidity and CostsAV Access Intervention


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Why measure flow during Angioplasty? Morbidity and Costs

  • 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.


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HVT100 Endovascular System Morbidity and Costs

  • 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


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Flow-Guided Angioplasty Morbidity and Costs

  • Measure baseline flow before

  • Angioplasty

  • Measure flow after angioplasty to confirm success.


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Catheter Types Morbidity and Costs

Antegrade

Retrograde


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K/DOQI Guidelines Morbidity and Costs


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Clinical Results Morbidity and Costs

  • 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 17:303-309, 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.


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Flow-Guided Angioplasty Morbidity and Costs

  • Confirms the Need

  • Confirms the Success


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Flow-based Morbidity and CostsAV Access Surgical Revision


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Flow-Guided AV Access Revision Morbidity and Costs

  • 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.


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Ischemic Steal Syndrome Morbidity and Costs DRIL Bypass

Distal revascularization interval ligation (DRIL)

is gaining acceptance as

an optimum way to manage ischemic steal syndrome (ISS).


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Flow Measurements during Morbidity and CostsDRIL

  • 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; 19:199-207.


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Flow-based Vascular Access Management Morbidity and Costs

Hemodialysis Monitor

Intraoperative Flowmeter

Endovascular Flowmeter


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Conclusion Morbidity and Costs

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


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Tissue Perfusion Morbidity and Costs

Extra-Corporeal

Research

Cardiovascular

Interventional Radiology

VAD performance / OEM

Neuro

Dialysis


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Major Perivascular Flow Measurement Applications Morbidity and Costs

  • CardiacSurgery

    • CABG:On&OffPump

  • arterialconduits

  • saphenousvein

  • CardiacOutput

  • adultascendingaorta

  • adultpulmonaryartery

  • pediatricheart

  • TransplantSurgery

  • Liver

  • hepaticartery

  • portalvein

  • Kidney

  • renalartery

  • renalvein

  • Pancreas

  • commoniliacartery

  • Cerebrovascular Neurosurgery

  • Cerebral arteries

  • EC-IC Bypass

  • VascularSurgery

    AVFistulas&Grafts

    radialartery

    brachialartery

    venousoutflowofgraft

    Abdominal

    renalbypass

    aortailiacshunt

    portal-cavalshunt

    spleno-renalshunt

    LowerExtremityBypass

    profundafemoris

    commonfemoral

    popliteal

    tibial

    CarotidEndarterectomy

    commoncarotidartery

    internalcarotidartery

    externalcarotidartery

    Pruit-InharaShunt

    JavidShunt


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    Transonic - Proven Morbidity and Costs

    • 25 Years of Excellence

    • Referenced in over 4,000 publications (www.transonic.com)

    • We are here to help with application and service needs


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    Thank You Morbidity and Costs


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