Learning Center

Module 4: Native Vein Arteriovenous Fistulae (AVF) for Dialysis Access

  • EXPIRED 

  • CME credits for this course are not currently available. You can still view the content.

  • Dates available 11/18/2020 - 11/18/2021

  • “This activity is jointly provided by Global Education Group and Kidney Academy.”

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  • This activity is supported by educational grants from Avenu Medical, BD (Becton, Dickinson and Company), and Medtronic.

Target Audience

The educational design of this activity addresses the needs of physicians and adjunct health care professionals (e.g., nurses, technologists) who treat kidney disease. Content is relevant to transplant surgeons, radiologists, interventionalists, and vascular surgeons.

Statement of Need/Program Overview

This module outlines basic principles for native vein AVFs. The wrist radio-cephalic anastomosis is described in detail as the surgical techniques are similar for different sites. Strict principles and meticulous practice of vascular surgical technique are paramount for success by in arteriovenous fistulas as patients are at high risk of uremia and renal failure associated comorbidity. While failure of an AVF may not be limb threatening as in other areas of vascular surgery the implications of a failed fistula may be wide reaching, particularly in younger patients adjusting to a lifetime of chronic disease. These techniques are covered in detail with short videos illustrating various anastomosis techniques.

Minimally Invasive Dialysis Access

Recent remarkable endovascular innovations have developed two minimally invasive procedures to create AVF fistula using one or two catheter techniques, respectively. Preliminary reports claim near 100 % technical success and a maturation rate in the 80-90 % range. This evolving technology has the potential to revolutionize hemodialysis access and is described in section 9. The percutaneous AVF  placements parallels a similar more recent event in peritoneal dialysis (PD) namely the new Modified Seldinger technique for placement of PD catheters. A complete module 16 at www.kidneyacademy.com  is covering the Percutaneous PD catheter placement. Together these technique have the potential to be gamechangers in  dialysis access in the near future. Both percutaneous hemodialysis and percutaneous PD technique rely heavily on the skillful use of ultrasound described in detail in module 15 at www.kidneyacademy.com  

Educational Objectives

After completing this activity, the participant should be better able to:

  • Explain the need for an integrated patient-centric model and functional infrastructure to manage RRT patients.

  • Recognize the value of an outcomes tracking system to assess performance and improvement.

  • Explain the function of ultrasound vascular mapping.

  • Describe vascular anatomy for selection of vessels appropriate for AVF.

  • Define atraumatic surgical techniques required to minimize initial hyperplasia such as juxta-anatomical stenosis.

  • Describe the benefits of an arteriovenous fistula in appropriately selected patients.

  • List the various types and selection of operative sites.

  • Identify the characteristics for a successful or mature arteriovenous fistula.

  • Identify the optimal time for arteriovenous fistula creation appropriate specialist referral path.

  • Describe the basic principles for evaluating a patient’s suitability for AVF, including physical exam and preoperative mapping with ultrasound.

  • Discuss the lesions associated with early arteriovenous fistula failure.

  • Outline principles in the evaluation of newly placed arteriovenous fistula to predict maturation.

  • Discuss the treatment of early arteriovenous fistula failure.

  • Describe the lesions associated with late fistula failure.

  • Outline fistula pathology, including high blood flow cardiac impact and implications of excessive blood flow management in an AVF.

  • Explain aneurysm formation and how to prevent them through proper cannulation techniques.

  • Describe the  innovations for percutaneous placement techniques of AVFs.

  • Describe the value of simulation training and opportunities available for AVF.

Faculty

Ingemar Davidson, MD, PhD, FACS
A native of Sweden, focusing in organ procurement, organ transplantation, and dialysis access in end stage renal disease patients, with published educational books on these topics.

Mohammed Sheta, MD

Gerald Beathard, MD, PhD
Founding member and the first president of the American Society of Diagnostic and Interventional Nephrology (ASDIN).

Nicholas Inston, MD, PhD
Transplant and dialysis access surgeon and clinical leader for Transplant Links, a charity organization providing hands-on training in kidney transplantation for surgeons, doctors and nurses in low/middle-income countries.

John Ross, MD
Founder of the Dialysis Access Institute (DAI), specializing in innovative approaches to dialysis access using the latest devices, techniques, and technology.

Jan Swinnen, MD
Vascular Surgeon / Dialysis Access Specialist at Westmead Hospital in Sydney, Australia. He is a qualified Sonographer (DDU Vascular) and runs the Westmead Vascular Ultrasound Lab. He is Professor of Surgery at Sydney University and has an interest in clinical research.

Program Agenda

Pre Test
Overview of AVF
Atraumatic Technique and Surgical Instruments
Surgical Techniques – Tips and Tricks for Wrist AVF
Basilic Vein Transposition Procedures
One Stage Basilic Vein Transposition Video Presentation
Complications of AVF
Endovascular Technique for Creating AVFs
Training in Dialysis Access
Summary
Post Test
Survey
Certificate

Physician Accreditation Statement

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Global Education Group (Global) and Kidney Academy. Global is accredited by the ACCME to provide continuing medical education for physicians.

Physician Credit Designation

Global Education Group designates this enduring activity for a maximum of 3.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Term of Offering

This activity was released on 10.15.20 and is valid for one year. Requests for credit must be made no later than 10.15.20.

Global Contact Information

For information about the accreditation of this program, please contact Global at 303-395-1782 or .

Instructions to Receive Credit

To receive credit for this activity, the participant must complete all sections and pass the post-test with at least 70% (11/15) questions answered correctly. The certificate will be available to download or print upon successful completion of the course material.

System Requirements
PC MAC
Microsoft Windows 2000 SE or above.
Flash Player Plugin (v7.0.1.9 or greater)
Internet Explorer (v5.5 or greater), or Firefox
Adobe Acrobat Reader* 		MAC OS 10.2.8
Flash Player Plugin (v7.0.1.9 or greater) Safari
Adobe Acrobat Reader* Internet Explorer is not supported on the Macintosh.
*Required to view printable (PDF) version of the lesson.
Fee Information& Refund/Cancellation Policy

There is a $150 fee for this educational activity.

Disclosure of Conflicts of Interest

Global Education Group (Global) requires instructors, planners, managers and other individuals and their spouse/life partner who are in a position to control the content of this activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly vetted by Global for fair balance, scientific objectivity of studies mentioned in the materials or used as the basis for content, and appropriateness of patient care recommendations.

The faculty reported the following financial relationships or relationships to products or devices they or their spouse/life partner have with commercial interests related to the content of this CME activity:

Name of Faculty or Presenter Reported Financial Relationship

Ingemar Davidson		  
Nothing to disclose
Mohammed Sheta

Gerald Beathard		 Nothing to disclose

Nothing to disclose
Nick Inston


Consultant/independent contractor: BD Bard/Merit Medical.Honoraria, Speaker’s Bureau and          Advisory Board: BD Bard
John Ross
Consultant/independent contractor: WL Gore, BD Bard, Medtronic, Boston  Scientific, Merit, Innavasc, Biotechs Medical, Phraxis Flex, and Nipro.

Jan Swinnen		  
 Nothing to disclose



The planners and managers reported the following financial relationships or relationships to products or devices they or their spouse/life partner have with commercial interests related to the content of this CME activity:

Name of Planner or Manager              Reported Financial Relationship
Lindsay Borvansky Nothing to disclose
Andrea Funk Nothing to disclose
Liddy Knight Nothing to disclose
Ashley Cann Nothing to disclose
Therese Wykoff Nothing to disclose
Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. Global Education Group (Global) and Kidney Academy do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of any organization associated with this activity. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

Key:

Complete
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SECTION 1: INTRODUCTION - NATIVE VEIN ARTERIOVENOUS FISTULAE (AVF) FOR DIALYSIS ACCESS
Renal Replacement Therapy (RRT) has four arms: Transplantation, Peritoneal dialysis (PD), Hemodialysis (HD) and Palliative support only ( End of Life care). Transplantation is the most cost effective and superior qualify of life in treating ESRD. For reasons of patient unsuitability (co-morbidities) and lack of available organs, transplantation remains the minority player in RRT worldwide, both in developed but more so in developing countries. As a stark reminder is the fact that only 10% of the world ESRD population has access to RRT to stay alive. The best overall outcomes in RRT, both for the patient and at the societal level, is achieved when all four arms of RRT are available, properly funded, efficiently run, and integrated with each other. The imbalance between funding and interest between transplant and the other RRT modalities effect both individual patient’s outcomes and cost to society. The effectiveness and inter-related complexity of RRT has been progressing over the last few decades. Keeping patients without native renal function alive, in good health and without complications in the long term, is now possible. This goal is not being achieved in most countries, not even in some of the world’s most developed societies. Although the modalities to achieve the above aims exist, they are often implemented in an inefficient and poorly coordinated way making the system both more morbid and more expensive than it needs to be. There are many options for renal replacement therapy (RRT) determined by patient factors, the access team skills and knowledge, and geographic policies and resources, to mention a few. Successful outcome is associated with continuous short and long-term life planning leading to the selection of the most appropriate access RRT for each individual patient at each timepoint, an overarching goal set by the new 2020 KDOQI guidelines (4). It follows that no mode of dialysis type and site of access should be considered superior, mandatory, or labeled ‘gold standard’. A strict comparison study between various forms of dialysis modes and access types has not been performed and would be unethical as each patient must be treated on an individual basis and specific needs at the time. Hence, many patients need several access types during their lifetime, for many including a renal transplant. Obviously, access modalities and types of access must not be competitive but rather complementary, reflecting individual needs at specific times over the patient’s lifetime. This module outlines basic principles for native vein AVFs selection and surgical techniques. The wrist radio-cephalic anastomosis is described in detail as the techniques are similar for different sites. Strict principles and meticulous practice of vascular surgical technique are paramount for success in AVFs, as patients are at high risk of uremia and renal failure associated comorbidity. While failure of an AVF may not be limb threatening as in other areas of vascular surgery the implications of a failed fistula are wide reaching, particularly in younger patients adjusting to a lifetime of chronic kidney disease. These techniques are covered in detail including linked video clips illustrating anastomosis techniques for an upper arm basilic vein transposition (BVT). A wrist radio cephalic AVF, although sometimes technically challenging, represents minor surgical trauma with little patient immediate morbidity. This contrasts with upper arm BVT procedures, representing major surgery, especially in the elderly and co-morbid patients. The concept of “right access for the right patient at the right time” is a core principal and now also the theme in the recently published 2020 KDOQI guidelines (4). Earlier published data suggest that AVFs have better long-term primary patency rate, decreased mortality, and requires fewer interventions and is associated with the lower morbidity compared to interventions involving grafts or catheters. These conclusions are flawed and are partly explained by the fact that patients having AVFs are about 10 years younger at the time of access placement and with less co-morbidity compared to those receiving a graft or restricted to a catheter access. Many factors influence the dialysis access outcome including referral patterns, such as delayed surgical referral, differences in the individual surgeon’s proficiency, insurance coverage, gender, and ethnicity. Maturation time for an AVF is usually several months compared to grafts and peritoneal dialysis catheters, that often can be used immediately or within 2-3 weeks. Dialysis access steal syndrome is more likely with distal brachial artery based AVFs, than with radial artery-based inflow. Recent endovascular innovations have developed two minimally invasive percutaneous procedures to create AVFs, using one or two catheter techniques, respectively. Preliminary clinical reports claim near 100 % technical success and a maturation rate in the 80-90 % range. This evolving technology has the potential to revolutionize hemodialysis access and is described in Section 10. Its role and place in dialysis access will take place over the next few years. This module describes detailed aspects of using native veins for dialysis vascular access (Table 1), and outlines dialysis access decision making (algorithm) in a simple fashion based on defined concepts as guiding principles to determine what to do, at any given time.
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SECTION 2: PRE-TEST
15 Questions  |  1 attempt  |  0/15 points to pass
15 Questions  |  1 attempt  |  0/15 points to pass
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SECTION 3: OVERVIEW OF AVF
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SECTION 4: ATRAUMATIC TECHNIQUE AND SURGICAL INSTRUMENTS
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SECTION 5: SURGICAL TECHNIQUE - TIPS AND TRICKS FOR THE WRIST AVF
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SECTION 6: BASILIC VEIN TRANSPOSITION (BVT) PROCEDURES
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SECTION 7: ONE STAGE BASILIC VEIN TRANSPOSITION VIDEO PRESENTATION
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SECTION 8: COMPLICATIONS OF AVF
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SECTION 9: ENDOVASCULAR TECHNIQUE FOR CREATING AVFs
Recent endovascular innovations have developed two minimally invasive techniques to create AVF fistulas using one or two catheter techniques, respectively. Both techniques use preoperative vascular mapping of the antecubital vessels to determine suitability for respective technique (1-7). Preliminary reports claim near 100 % technical success and a AVF maturation rate in the 80-90 range as well as low re-intervention rates to maintain patency. This evolving technology has the potential to markedly affect the future hemodialysis access algorithms. Its role and place in dialysis access will be defined over the next several years.
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SECTION 10: TRAINING IN DIALYSIS ACCESS
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SECTION 11: SUMMARY OF MODULE 4 ON NATIVE VEIN AV FISTULA
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SECTION 12: ADDITIONAL REFERENCES
Open to download resource.
Open to download resource. Expanded references for Module 4: AVF is provided by Gerald A Beathard, MD, PhD.
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SECTION 13: POST-TEST
15 Questions  |  Unlimited attempts  |  11/15 points to pass
15 Questions  |  Unlimited attempts  |  11/15 points to pass
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SECTION 14: POST MODULE SURVEY
10 Questions
10 Questions
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SECTION 15: PRINT CERTIFICATE
No credits available  |  Certificate available
No credits available  |  Certificate available
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