P1252428293iZEJP

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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 patients 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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Flow-based Access Creation
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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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Transit-Time Ultrasound (TTU)
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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 0.930.95) 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
200070212217.
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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 (Dont
  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)729738, 1998.

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Fistula Flow Patency Results
Flow Measurements taken 5-10 minutes after anastomosis Failure within 30 days Requiring Intervention Failure within 30 days Requiring Intervention
Radiocephalic Fistula Radiocephalic Fistula Radiocephalic Fistula
Flow lt 170 ml/min 56 P.001
Flow gt 170 ml/min 15 P.001
Brachiocephalic Fistula Brachiocephalic Fistula Brachiocephalic Fistula
Flow lt 280 ml/min 64 P.01
Flow gt 280ml/min 18 P.01
Johnson, CP et al, Prognostic Value of
Intraoperative Blood flow Measurements in
Vascular Access Surgery, Surgery 124(4) 729738,
1998.
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AV Fistula Guidelines
Flow rates lt 100 ML/min Abandon Immediately, unless correctable
Flow between 100 and 300 mL/min Monitor Closely. At risk for early failure
Johnson, CP et al, Prognostic Value of
Intraoperative Blood flow Measurements in
Vascular Access Surgery, Surgery 124(4)729738,
1998.
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Clinical Results - Fistula

• Berman 72 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
AV Fistula Type Threshold to predict Maturation
Radiocephalic 179 mL/min
Brachiocephalic 308 mL/min
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)729738,
  1998.

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PTFE Graft Flow Guidelines cont.
lt 250 mL/min Consider abandoning
250-400 mL/min Consider prophylactic anticoagulation
Johnson, CP et al, Prognostic Value of
Intraoperative Blood flow Measurements in
Vascular Access Surgery, Surgery 124(4)729738,
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/guidelin
e_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/guidelin
e_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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Indicator Dilution Flow Measurements
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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
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K/DOQI Guidelines for Monitoring AV Grafts and
Fistulas

• Access flow lt 600 ml/min, the patient should be
  referred for fistulagram.
• Access flow lt 1000ml/min that has decreased by gt
  25 over 4 months should be referred for
  fistulagram.

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Monthly Access Flow Trending
K/DOQI Guideline lt600 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
Phase Duration Monitoring Technique
I 11 Months None
II 12 Months Dynamic V.P.
III 10 Months Transonic HD01
132 Hemodialysis Patients with A-V grafts or
fistulas.
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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
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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
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Flow-QC in HD
Preserve an Access - Save a Live
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Flow-based AV Access Intervention
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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.
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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
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Flow-Guided Angioplasty

• Measure baseline flow before
• Angioplasty
• Measure flow after angioplasty to confirm success.

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Catheter Types
Antegrade
Retrograde
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K/DOQI Guidelines
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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 17303-309, 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

• Confirms the Need
• Confirms the Success

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Flow-based AV Access Surgical Revision
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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.

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Ischemic Steal Syndrome
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 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 19199-207.
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Flow-based Vascular Access Management
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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
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Tissue Perfusion
Extra-Corporeal
Research
Cardiovascular
Interventional Radiology
VAD performance / OEM
Neuro
Dialysis
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Major Perivascular Flow Measurement Applications
Vascular Surgery AV Fistulas  Grafts radial art
ery brachial artery venous outflow of graft Abdom
inal  renal bypass aorta iliac shunt
portal-caval shunt spleno-renal shunt  Lower E
xtremity Bypass  profunda femoris  common femoral
popliteal tibial  Carotid Endarterectomy common 
carotid artery  internal carotid artery  external 
carotid artery Pruit-Inhara Shunt Javid Shunt
Cardiac Surgery  CABG On  Off Pump arterial co
nduits  saphenous vein Cardiac Output  adult asce
nding aorta adult pulmonary artery pediatric heart
Transplant Surgery Liver hepatic artery portal 
vein Kidney renal artery  renal vein  Pancreas 
common iliac artery  Cerebrovascular
Neurosurgery Cerebral arteries EC-IC Bypass
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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

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