Vascular Access creation in the USA surgical perspective

Surendra Shenoy M.D., Ph.D.

Section of TransplantationDepartment of Surgery

DisclosuresNo specific disclosures pertaining to

the topic of presentation

50thAnniverseryofInternal (access) shunts

Brescia MJ, Cimino JE, Appel K , Hrwich BJ NEJY;1966:1089

Cimino Appel Brescia

Cimino Appel Brescia

Brescia Cimino AppelXXXXXXXXX

Vascular Access in USSurgical perspective….. Background

Vascular Access in USSurgical perspective

Health care changes in US: Impact on VA

Social Security Amendments – 1972All persons with ESRD eligible for medicare

Assured reimbursement

Improved access to healthcare

Physician’s Behavioral change

USRDS ADR Ch XII 1994

Patient profile: elderly, diabetics, ↑ co morbidities

Increased experience better care and longevity

Beneficiaries 10,000 (1970) to >150,000 (1990)

Background

Background

• Fistulae better than shunts• Need for anatomic suitability• Maturation period• Uncertainty of success

Vascular Access in USSurgical perspective….

Problems with vascular access

AVGBiologic

Xenografts Allograft

Cross linkedCross link

Synthetic

1978 - Human Umbilical vein(Biograft ®, Meadox Meds)- Saphenous vein

1972- Bovine carotid artery(Artegraft ®, Artegraft Inc)

Non cross linkednon antigenic Cryopreserved

(1985) antigenic

Non cross linked

1976

- ePTFE

AVFMultitudes of sites with very little technical changes Snuff box,high & low wrist fistula, brachiocephalic, Gracz AVF, basilicatransposition UA, basilic transposition FA

No attention paid to cause of failure – no need due to short longevity

Background

Goodkin DA et.al. JASN 2003; 14: 3270

NKF-KDOQI (1995)

‘Fistula First’ (2003)

Vascular Access in USSurgical perspective….

Access population differences Access modality differences Outcome differences

US ESRD population (200,000) ~ 80% AVGJapan ESRD (175,00) ~ 85% AVFEuropean ESRD (30,000) ~ 80% AVF

Schena FP Kidney Int 2000; 57: S39-45

Increaseddialysis dose

Decreased BP Phos control

Decreased LVH Better nutritionImproved QOL

Williams AW. AJKD 2004;43:90 Kliger AS. CJASN 2009;4:S121

Quality of dialysis depends onfunctioning of vascular access

RAS inhibitors, statins, BP control, Phos control, fluid control etc.

AVG, Catheters and AVF

Strategies to improve ESRD mortality(2000-present)

Vascular access practice patternsAccess performed by well-trained surgeonsSurgeons trained in graft eraMinimal experience in AVFAccess = joining a vein/graft to arteryHigh rates of primary failure TDC prevalence

Dember LM et.al. JAMA 2008;299:2164-71

Origin and proliferation of image guidedprocedures and devices and catheter industry

Lacson E, et.al. AJKD 2007; 50:379-95

Adaptation of medical communityto changing practice pattern

Individual dataAVF 79%

AVG 21%

Functional AVF maturation 81.7%

Committed to catheter 3.5%

AVF maturation (ITT) 72%

1 yr. Primary patency 42.5%

1 yr. Secondary patency 81.8 %

Median (range 1.2 - 97.7 mon) followup 36.1 mon

AVF procedures per functional year 0.68

Patient outcome >85% AVF

VA creation: Changing outcome

Richardson AI et.al. JVA 2009; 10: 199-02 Dember LM et.al. JAMA 2008;299:2164-71Jennings WC. Arc Surg 2006; 141:27-32 Lucas J. J Vasc Surg 2016;

VA surgical practice patternsLarge Academic Medical center

~ 300 cases in 1 year by 8 surgeons 2 Surgeons performed >60% of procedures These surgeons performed >80% AVF One recent trainee also performed >80% AVF Other surgeons performed AVF ~ 50% patients

Patterns reflect a changing practicepatterns showing improvement in training

and importance of access championsVachharajani N,et.al. J Vasc Surg 2015: s1-s4

17%

65%

20%

AVF

Catheter

80%

USRDS 2015

VA patterns in incident patientsCMS 2728 & crown web data 2013

Vascular access surgical training

Eidt JF. JVS 2011; 53: 1130-40

Vascular Board certification data300% increase in AVF (5 in 2003 to 18)

VA is considered a resident case19 residents graduated between 2012 -2014

Required vascular cases 44Average AVF/AVG(range 11-73) 33Revisions (range 1-27) 11Trainees interested in VA 62

Current surgical trainingprovides ample opportunity

Vachharajani N,et.al. J Vasc Surg 2015: s1-s4

What are some issues?Difficulty to make AVA attractive

High rates of failure

Lack of scientific understanding

Lack of innovative research

Multidisciplinary nature of the practice

Fragmentation of careLack of advocacy

Inflow

Central outflow

PeripheralOutflow

NAS(Needle access

Segment)

Stenosis is the cause for majority of access circuit failure

Capacity of the pumpdiameter, stiffness & length

of the tubesdetermines the flow

Physiology: AVA maturation & failure

AVG is NAS of the circuit

Where we are now?

Growing patient population will propelchanges in the field

USRDS 2015

~ 117,000 patients started dialysis in 2012

Total ESRD population ~661,648Hemodialysis (91%) ~421,000Peritoneal Dialysis (9%) ~ 45,000Post transplant ~ 193,000

SummarySurgical problems associated with

vascular access were part of the evolutionof the speciality.

The current eduction system is robustenough to adjust the need of the changing

practice patterns.There is a need for better understandingand research in the field to improve the

current outcomeIncreasing prevalence of ESRD will

continue to fuel the progress andinnovation

Vascular Access creation in the USA surgical perspective