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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 Transcript
slide1

Presentation for:

Tri-Service General Hospital

July 22nd, 2008

flow based vascular access management
Flow-BasedVascular Access Management

A Quantitative approach to preserving access patency;

A patient’s link to life

flow based
Flow-Based
  • Surgical Creation
  • of the access
  • Hemodialysis
  • Surveillance
  • Angioplasty or
  • Surgical Revision
vascular access management tools
Vascular Access Management Tools

Intraoperative Flowmeter

Endovascular Flowmeter

Hemodialysis Monitor

ht300 series flowmeters
HT300-Series Flowmeters
  • Mean Volume Flow Digital Display
  • Wave-Form printer
  • FlowSound
  • Inversion button (+/-)

Above - HT313 , Below -HT323

transonic fmv vascular flowprobes
Transonic (FMV) Vascular Flowprobes
  • Available in a wide range of sizes (1.5 to 14 mm)
  • Reusable
  • Steam, EtO and Sterrad Sterilizable
slide9
TTU

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

validation transit time ultrasound
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.

clinical technique
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)
movies if available
Movies (If available)

Applying Gel

Applying Flowprobe to Vessel

Flowsound

Documenting Waveform

end to side anastomosis
End-to-side anastomosis

Measure Venous Outflow

side to side anastomosis
Side-to-Side Anastomosis

Measure Venous Outflow

clinical results fistulas
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.

fistula flow patency results
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.

av fistula guidelines
AV Fistula Guidelines

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

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

clinical results fistula
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.

fistula guidelines
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.

ptfe grafts
PTFE Grafts

Air in the graft interstices block ultrasound transmission.

Therefore, measure at the distal outflow of the graft.

clinical results grafts
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.

ptfe graft flow guidelines cont
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.

flow qc measurements
Flow-QC Measurements
  • Quick, accurate, and easy to perform
  • May indicate corrections during surgery
  • Can predict the ultimate survival of an AV access
flow based surveillance
Flow-based Surveillance

during Hemodialysis

k doqi
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

k doqi goal
K/DOQI Goal:
  • Detect access dysfunction prior to access thrombosis.

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

k doqi suggested technology
K/DOQI Suggested Technology
  • Indicator dilution (Transonic) flow measurements are the preferred method of A-V graft and fistula surveillance.
transonic flow qc hemodialysis monitor
Transonic Flow-QC® Hemodialysis Monitor

The Standard of Care for the ESRD patient

hd monitor parameters
HD Monitor Parameters
  • Dialysis Adequacy
    • Delivered Blood Flow
    • Recirculation
  • Vascular Access Flow
  • Cardiac Output
k doqi guidelines for monitoring av grafts and fistulas
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.
monthly access flow trending
Monthly Access Flow Trending

K/DOQI Guideline: <600 ml/min

Documented Intervention

clinical results
Clinical Results
  • Gambro Study
  • McCarley Study
gambro study
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.

vascular access blood flow monitoring reduces access morbidity and costs
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

three phase study
Three-Phase Study

132 Hemodialysis Patients with A-V grafts or fistulas.

europe
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

japan
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

flow qc in hd
Flow-QC in HD

Preserve an Access - Save a Live

why measure flow during angioplasty
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.

hvt100 endovascular system
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

flow guided angioplasty
Flow-Guided Angioplasty
  • Measure baseline flow before
  • Angioplasty
  • Measure flow after angioplasty to confirm success.
catheter types
Catheter Types

Antegrade

Retrograde

clinical results50
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 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.
flow guided angioplasty51
Flow-Guided Angioplasty
  • Confirms the Need
  • Confirms the Success
flow guided av access revision
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.

ischemic steal syndrome dril bypass
Ischemic Steal Syndrome DRIL Bypass

Distal revascularization interval ligation (DRIL)

is gaining acceptance as

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

flow measurements during dril
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; 19:199-207.

flow based vascular access management56
Flow-based Vascular Access Management

Hemodialysis Monitor

Intraoperative Flowmeter

Endovascular Flowmeter

conclusion
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

slide58

Tissue Perfusion

Extra-Corporeal

Research

Cardiovascular

Interventional Radiology

VAD performance / OEM

Neuro

Dialysis

slide59

Major Perivascular Flow Measurement Applications

  • 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

transonic proven
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