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In 2021, the SVS approved a membership section dedicated to vascular surgeons in the first 0-10 years of practice. The mission of the Young Surgeons Section (YSS) of the SVS is to foster and accelerate the learning and career development of SVS members within their first ten years in clinical practice. We are excited to have Dr. Chelsea Dorsey and Dr. Leigh Ann O’Banion to discuss the evolution of the YSS, their plans for the upcoming VAM, and how people can get involved.  

Dr. Chelsea Dorsey (@MdDorsey) is an Associate Professor of Surgery in the Section of Vascular Surgery at the University of Chicago and serves as the Vice Chair of Diversity, Equity and Inclusion in the Department of Surgery.  In keeping with her medical education interests, she was recently appointed the Associate Dean for Medical Student Academic Advising and Advancement at the Pritzker School of Medicine. She currently sits on a number of regional and national committees focused on surgical education and also serves on the SVS Communications and Appointments Committee.  In January of this year, she was formally appointed the Chair of the newly formed SVS Young Surgeons Section.  

 

Dr. Leigh Ann O'Banion (@limbsalvagedr) is an Assistant Professor of Vascular Surgery at UCSF Fresno, where she also completed her general surgery residency. She did her fellowship in vascular surgery at UCSF, graduated in 2017 and then returned to UCSF Fresno as an attending. She has a busy clinical practice with a focus on limb salvage and outcomes of vascular amputees and shares a passion for mentoring the next generation of vascular trainees. She is on the steering committee of the Young Surgeons Section of the SVS.

 

Young Surgeon Section  page on the SVS website

 

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In this episode, we are fortunate to hear three interviews from guest experts in the field discussing occupational hazards in vascular surgery. We cover physical pain and discomfort with Dr. Max Wohlauer, radiation safety with Dr. Melissa Kirkwood, and pregnancy and radiation with Dr. Venita Chandra. 

Show Guests:

Dr. Max Wohlauer (@doctormaxw) is an assistant professor at the University of Colorado School of Medicine, as well as an associate program director of their residency and fellowship.  He founded the Vascular Surgery COVID-19 Collaborative (VASCC, https://medschool.cuanschutz.edu/surgery/divisions-centers-affiliates/vascular/research/vascc/vascc).  He obtained his medical degree from the Albany Medical College and completed general surgery residency at the University of Colorado followed by vascular surgery fellowship at the Cleveland Clinic.

• Audible Bleeding with Dr. Samuel Money on Ergonomics in Surgery: https://www.audiblebleeding.com/money-ergonomics/ 
• Physical discomfort, professional satisfaction, and burnout in vascular surgeons: https://doi.org/10.1016/j.jvs.2018.11.026 
• Physical pain and musculoskeletal discomfort in vascular surgeons: https://doi.org/10.1016/j.jvs.2020.07.097 
• Vascular surgeon wellness and burnout: A report from the Society for Vascular Surgery Wellness Task Force: https://doi.org/10.1016/j.jvs.2020.10.065 

Dr. Melissa Kirkwood is an associate professor at the UT Southwestern Medical Center and chief of the division of vascular surgery. She completed her medical degree at Yale University School of Medicine, followed by a general surgery residency at The University of Chicago, and vascular surgery fellowship at the University of Pennsylvania Medical Center. One of her major research interests is radiation dose control and novel technology for decreasing radiation exposure.

• Dual fluoroscopy with live-image digital zooming significantly reduces patient and operating staff radiation during fenestrated-branched endovascular aortic aneurysm repair: https://doi.org/10.1016/j.jvs.2020.05.031 
• Disposable, lightweight shield decreases operator eye and brain radiation dose when attached to safety eyewear during fluoroscopically guided interventions: https://doi.org/10.1016/j.jvs.2021.11.067 
• Radiation brain dose to vascular surgeons during fluoroscopically guided interventions is not effectively reduced by wearing lead equivalent surgical caps: https://doi.org/10.1016/j.jvs.2017.12.054 

 

Dr. Venita Chandra (@ChandraVenita) is a clinical associate professor at Stanford University as well as the program director for vascular surgery residency and fellowship. She obtained her medical degree from the University of Chicago followed by general surgery residency and vascular surgery fellowship at Stanford University. She also completed a technology development fellowship in the Stanford Biodesign Program. She is part of the SVS Wellness Task Force and has an interest in radiation safety in pregnancy.

• Monitoring of fetal radiation exposure during pregnancy: https://doi.org/10.1016/j.jvs.2013.01.052
• Incidence of Infertility and Pregnancy Complications in US Female Surgeons: https://doi.org/10.1001/jamasurg.2021.3301  

Host Introductions:

Dr. Matt Chia (@chia_md) is in his 6th year in the integrated vascular surgery program at Northwestern University. He obtained his medical degree from the University of Illinois College of Medicine, and also holds a Master’s in Health Services and Outcomes Research from Northwestern. 

 

Dr. Jessie Ho (@JessieHo_) is in her 4th year general surgery resident at Northwestern University. She obtained her medical degree from the Texas A&M College of Medicine, and is completing a Master’s in Clinical Investigation at Northwestern.

 

Authors: Matt Chia, MD, MS, Jessie Ho, MD, Janhavi Patel, BMSc

Editor: Matt Chia, MD

Reviewers: Sharif Ellozy, MD, Adam Johnson, MD

As part of the Race & Representation (R&R) Series, we are doing spotlights on vascular trainees and faculty that identify as racial/ethnic minorities underrepresented in medicine (URiM), who have been historically excluded from the field. We hope to amplify these voices as examples of the unique challenges faced by URiMs within vascular surgery and as a source of inspiration and mentorship.

In this episode, Imani talks with Dr. Eric Pillado about his experiences thus far in training, finding comfort in being himself, and his ambitions in addressing health disparities in Latin-X and Spanish-speaking populations. 

Dr. Pillado (@drpillado) is an integrated vascular trainee at McGaw Medical Center of Northwestern University. 

• To read Dr. Pillado’s perspective piece “Being Queer Without Proximal or Distal Control”. 
• To learn more about The Surgical Outcomes & Quality Improvement Center (SOQIC) and the SECOND Trial.

What other topics would you like to hear about? Let us know more about you and what you think of our podcast through our Listener Survey or email us at [email protected].

Holding Pressure AKA/BKA Shownotes

 

Name of Surgery: Above Knee Amputation/Below Knee Amputation

 

Authors:

Dominique Dockery, MS3, Alpert Medical School of Brown University

Robert Patterson, MD, FACS, Alpert Medical School of Brown University/Providence Surgical Care Group

 

Editor: 

Yasong Yu

 

Reviewer:

Ryan Meyer

 

Core Resources:

• Rutherford's Vascular and Endovascular Therapy 9th Edition Chapters 104, 105, 111, 112
• Anson and McVeigh’s Surgical Anatomy

 

Additional Resources:

• Article Explaining WIfI (https://www.jvascsurg.org/article/S0741-5214(13)01515-2/fulltext) 
• Links to Apps for CLTI Calculators (https://vascular.org/news-advocacy/society-vascular-surgery-launches-mobile-apps-staging-chronic-limb-threatening) 
• Callander Technique Original Article (https://jamanetwork.com/journals/jama/article-abstract/1155011)
• Logan, Meryl Simon & Bush, Ruth L. Vascular surgeons are health disparities doctors. JVS. Vol 74; Issue 5p1437. November 2021. 

 

Underlying disease featured in episode: Peripheral arterial disease (PAD)/chronic limb threatening ischemia (CLTI)

1. Pathophysiology/etiology
   • Blockage of the arteries supplying blood to the lower limbs usually secondary to atherosclerosis
     • Affects an estimated 8-12 million Americans
     • Associated with smoking, diabetes, hypertension, obesity
     • CLTI is more severe form of PAD (up to 20% of PAD patients)- associated with rest pain, ischemia ulceration, or gangrene

1. Patient presentation

• Varies based on disease progression and prior intervention
  • Ranges from asymptomatic to major tissue loss
  • Often have patients with intermittent claudication, rest pain, or wounds/ulceration
• Patients can be classified using Rutherford scale or WIfI classification

1. Diagnosis

• Ankle-brachial index is diagnostic (1.3)
• Often obtain CTA with run-off to visualize vessels prior to angiogram
• Angiogram to plan intervention

1. Surgical treatment 

• Revascularization: either endovascular (angioplasty vs stenting) or open (bypass based on targets with either vein or graft)
• Amputation: after failed revascularization or irreversible/severe ischemia with no revascularization options
  • Minor (toe/foot) vs major (below knee/through knee/above knee)

 

Indications for surgery: 

1. acute ischemia: for irreversible ischemia, for severe ischemia with no revascularization options, or following unsuccessful attempts at revascularization
2. chronic ischemia: failure of revascularization, lack of suitable conduit or target arteries, severe patient comorbidities, poor functional status, or extensive gangrene or infection such that foot salvage is not possible
3. foot infection
4. severe traumatic injury
5. lower extremity skeletal or soft tissue malignancy

 

Preop Preparation: linking the patient with a prosthetist prior to surgery is ideal and helps with surgical planning, addressing patients’ fears and concerns, determining level of amputation (pulses/blood flow, level of infection, etc.)

 

Surgical steps with relevant images: 

Below the knee amputation (posterior flap technique):

1. Create a hemi-circular incision anteriorly (generally about 1 handbreadth below the tibial tuberosity that goes from just anterior to the fibula to an equidistant portion of the other side) and a long posterior flap 
2. Cut through the muscles of the anterior compartment (muscle bundle on the lateral side of the tibia) and expose the anterior tibial artery and vein- ligate and suture ligate
3. Using a periosteal elevator, which is something like a chisel, strip the periosteum proximally from the tibia and divide the tibia with an oscillating saw. Then strip the periosteum and attachments of the fibula at this level and divide either with the saw or a bone shear. 
4. Use an amputation knife to create the posterior flap along the skin and fascia incision lines (fashion it to make sure it will reach anteriorly without muscle bulk/tension). The remaining tibial vessels are then identified and individually suture ligated. Identify the tibial nerve, bluntly dissect it quite proximally and divide it with electrocautery. 
5. After hemostasis has been established, remove a wedge of bone from the anterior portion of the tibia so that that doesn’t provide a pressure point on the prosthesis and resect the fibula 1-2 centimeters above the line of tibial transection with a rib cutter to be sure that the fibula doesn’t wear against the prosthesis laterally and create an ulceration or painful protrusion.
6. Loosely approximate the posterior flap to the anterior fascia with several interrupted Vicryl sutures and then carefully re-approximate the skin with vertical mattress sutures of Prolene using a Keith needle to avoid traumatizing the skin with forceps. 

 

Above knee amputations (Callander technique): Does not cut across any muscle bellies but is purely dividing all muscular attachments through the tendinous insertions. It is similar to a through the knee amputation, but it involves dividing the femur immediately above the flare of the condyle with curved anterior and posterior fish mouth type flaps that again allow division without the trauma of muscular transection.

 

Postoperative care: knee immobilizer post-operatively after BKA to reduce risk of contractures, non–weight bearing on the stump until the fitting of a prosthesis 4 to 6 weeks after surgery, close follow up with vascular surgeon

 

Complications: primary healing fails in 20% to 30% of patients and approximately 1 in 5 patients undergoing BKA need a higher-level amputation due to wound problems

 

Top Asked Questions:

 

1. What ankle-brachial index is diagnostic of peripheral arterial disease?

 

Less than 0.9, severe PAD is less than 0.4. An ABI greater than 1.3 or 1.4 is considered non-diagnostic and further workup is indicated.

 

1. What is the Rutherford classification for peripheral arterial disease?

 

0- asymptomatic, 1- mild claudication, 2- moderate claudication, 3- severe claudication, 4- ischemic rest pain, 5- minor tissue loss, 6- major tissue loss 

 

1. Which amputation level requires more energy to ambulate with a prosthesis? 

 

Above knee amputations require 50-70% more energy than below knee amputations

1. What are the compartments of the lower leg, and which major vessels and nerves are in each compartment?

 

Anterior- anterior tibial artery and vein, deep peroneal nerve

Lateral- superficial peroneal nerve

Deep posterior- posterior tibial artery and vein, peroneal artery and vein, tibial nerve

Superficial posterior- mostly musculature

We are very excited to have Dr. Kellie Brown, the current Vice-Chair of the Vascular Surgery Board, and Dr. Malachi Sheahan, the Vice-Chair Elect, to pull back the curtain on how the VSB serves the public and the vascular surgery community at large while defining our specialty. They discuss the history of the VSB, provide some insight into board examination development, and clarify the process of Continuous Certification Assessment. They also discuss the new nomination process adopted this year by the VSB, and how interested people can get more involved. 

 

Dr. Kellie Brown is Professor of Surgery and Radiology in the Division of Vascular and Endovascular Surgery at The Medical College of Wisconsin, and the Chief of Vascular Surgery at the Zablocki VA Medical Center. She is the Program Director for the Vascular Surgery Fellowship at the Medical College of Wisconsin. 

 

Dr. Malachi Sheahan is Professor of Surgery and Chair of Vascular and Endovascular Surgery and Program Director for the Vascular Surgery Integrated Residency and Fellowship at LSU Health Sciences Center in New Orleans. 

 

Vascular Surgery Continuous Certification Assessment

VSB Update - Spring 2021

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Learn more about us at https://www.audiblebleeding.com/about-1/ and #jointheconversation.

Have you ever wondered how physicians create new medical technology or how they receive funding for creating new medical products? Five entrepreneurs, who have developed medical products and received funding, will share the process of developing a company and the different types of funding. This webinar is presented by the SVS Health Information Technology Committee.

Webinar Faculty:

• Anahita Dua, MD, MS, MBA - Asst. Prof., Harvard Medical School
• Sophia Khan, MD - Asst. Prof., UTHealth; CEO & Founder, Voythos AI
• Pratap Khanwilkar, PhD, MBA - Vice-President, InCube Labs
• Dave Kuraguntla, MD - Founder & CEO, Alio
• Hari Radhakrishnan, MD - Co-Chief Executive Officer, Decisio Health, Inc.

Moderators:

• Judith Lin, MD, MBA - Prof. & Chief, Vascular Surgery, Michigan State University College of Human Medicine
• Shivprasad Nikam, MD, MBA - Vascular Surgeon, Geisinger; President & CEO, Mundaii

Join us on May 4 for the next HITC Webinar - New Technologies in Vascular Surgery. Register Here

As part of the Race & Representation (R&R) Series, we are doing spotlights on vascular trainees and faculty that identify as racial/ethnic minorities underrepresented in medicine (URiM), who have been historically excluded from the field. We hope to amplify these voices as examples of the unique challenges faced by URiMs within vascular surgery and as a source of inspiration and mentorship. 

In this episode, Imani talks with Dr. Garietta Falls about her journey to vascular surgery and the lessons she learned along the way. 

Dr. Falls (@drgfalls) is an assistant professor at Case Western Reserve School of Medicine and also serves as the director of the vascular lab at Metro Health in Cleveland, Ohio. 

For more information on the Midwestern Vascular Society

For more information on the goals and objectives of the SVS DEI Committee 

What other topics would you like to hear about? Let us know more about you and what you think of our podcast through our Listener Survey or email us at [email protected].

Follow us on Twitter @audiblebleeding

Learn more about us at https://www.audiblebleeding.com/about-1/ and #jointheconversation.

Adam and Farooq discuss Journal of Vascular Surgery Editor’s Choice articles for April 2022 with the Senior Editor, Dr. Peter Lawrence.

Video Summary of the Articles

Articles Discussed

• Treatment of carotid stenosis in asymptomatic, non-octogenarian, standard risk patients with stenting versus endarterectomy trials.
• Predictors of mortality in nonagenarians undergoing abdominal aortic aneurysm repair: Analysis of the National Surgical Quality Improvement Program dataset.
• Hospital-based delays to revascularization increase risk of postoperative mortality and short bowel syndrome in acute mesenteric ischemia.
• Outcomes of carotid artery stenting in patients with radiation arteritis compared with those with atherosclerotic disease.

JVS Journal Club Website

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Credits:

• Guest: Peter Lawrence
• Authors: Adam Johnson and Farooq Usmani
• Editor: Adam Johnson
• Reviewers: Shivik Patel

Holding Pressure and Vascular Origin Stories: History of Hemodialysis Access

 

In this crossover episode of Holding Pressure and Vascular Origin Stories Gowri and Marlene explore the history of hemodialysis access, the creation of arteriovenous fistulas and prosthetic grafts. During this episode Gowri interviews Dr. Appell- the surgeon who created the first AV fistula for hemodialysis access and Marlene interviews Dr. Schanzer about his experience with early hemodialysis access and the development of the distal revascularization and interval ligation procedure.  Below you can find a picture of the first Teflon shunt used for hemodialysis, The Artificial Kidney Center Admission and Policy Committee (aka ‘God Squad’), evolution of early A-V shunts and Drs. James E Cimino, Kenneth Appell, Michael J. Brescia. 

 

Links to other podcasts on bioethics and finance of hemodialysis and the God Squad:
Beside Rounds: Episode 26 The God Squad

 

Freakonomics: Is dialysis a test case of medicare for all?

References:

[1] Klaus Konner. History of vascular access for haemodialysis. Nephrol Dial Transplant (2005) 20: 2629–2635.

 

[2]  B.H. Scribner, R. Buri, J.E.Z. Caner, R. Hegstrom, J.M. Burnell. Preliminary report on the treatment of chronic uremia by means of intermittent hemodialysis. Trans Am Soc Artif Intern

Organs 1960; 6: 114–12.

 

[3]  Wayne Quinton, David Dillard, and Belding H. Scribner Authors. Cannulation of Blood Vessels for Prolonged Hemodialysis. Transactions of the ASA10, 1960, Vol. 6, pp. 104–107.

 

[4] Brescia MJ, Cimino JE, Appel K, Hurwich BJ. Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N Engl J Med 1966; 275: 1089–1092

 

[5] Cimino JE, Brescia MJ. The early development of the arteriovenous fistula needle technique for hemodialysis. ASAIO J 1994; 40: 923–927

 

[6] Scribner. Hemodialysis Using an Arteriovenous Fistula. N Engl J Med 1966; 

 

[7] Baker, L. D., Jr, Johnson, J. M., & Goldfarb, D. (1976). Expanded polytetrafluoroethylene (PTFE) subcutaneous arteriovenous conduit: an improved vascular access for chronic hemodialysis. Transactions - American Society for Artificial Internal Organs, 22, 382–387.

 

[8] Blagg, CR. Development of ethical concepts in dialysis: Seattle in the 1960s. Nephrology  1998; 4, 235-238

 

[9] Blagg CR. The Early History of Dialysis for Chronic Renal Failure in the United States: A View From Seattle. World Kidney Forum.

 

[10] Rettig, RA. Origins of the Medicare Kidney Disease Entitlement: The Social Security Amendments of 1972. Biomedical Politics. Institute of Medicine (US) Committee to Study Decision Making; 1992

 

[11] Scribner, B. Treatment of Chronic Uremia. 

 

[12] United States Renal Data System. 2020 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2020.

 

[13] Scribner, Belding. A Personalized History of Chronic Hemodialysis. American Journal of Kidney Diseases. Vol XVI No 6. December 1990. pp511-519

Hosts:

Marlene Garcia-Neuer (@GarciaNeuer) is a MS4 at THE Ohio State University College of Medicine.

 

Gowri Gowda (@GowriGowda11)  is an MS3 at Tulane University School of Medicine. 

 

Guests:

Dr. Harry Schanzer, Vascular Surgeon Mount Sinai Hospital and Bronx VA (retired)

 

Dr. Kenneth Appel, General Surgeon, Bronx VA (retired)

Calling all medical students!

Submit your questions for the mailbag episode! Ask us any question related to vascular surgery, and have it answered on the podcast. 

Include the following

• Your name, school, and year
• Who you want to address the question to (resident, fellow, attending, or someone specific)
• Send them in writing, or in voice recorded format. 

 

Send them to [email protected]. Also send us any ideas, suggestions, or comments.

 

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Follow us on Twitter @audiblebleeding

 

Learn more about us at https://www.audiblebleeding.com/about-1/ and #jointheconversation.

Please share your feedback through our Listener Survey!

 

Credits:

Author: Marlene Garcia-Neuer, Gowri Gowda

Editor: Yasong Yu

Reviewers: Sharif Ellozy, Adam Johnson

Holding Pressure AVF/AVG Creation Show Notes

Name of Surgery: AVF/AVG Creation

 

Authors: 

Gowri Gowda, Tulane University School of Medicine, MS3

Daniela Medina, Penn State College of Medicine, MS4

Dr. Gerry Victor, LSU Health New Orleans, PGY1

 

Editor: 

Yasong Yu

 

Reviewers:

Amanda Fobare

Farooq Usmani

 

Core Resources:

• Rutherford's Vascular and Endovascular Therapy 9th Edition Chapter# 175,176,178,179

 

Additional Resources:

• Landmark paper:  benefits of regional vs local anesthesia on AV fistula outcomes titled“Effect of regional versus local anesthesia on outcome after arteriovenous fistula creation: a randomized controlled trial”  by Aitken et. al found that regional brachial plexus block anesthesia results in greater vasodilation and increased short-term blood flow was associated with higher primary patency at 3 months compared to local anesthesia. 
• SVS reporting standards for HA access: reference for surgical dialysis access placement and revision 
• VSITE Review - Vascular Access

 

Underlying disease featured in episode

1. Pathophysiology/etiology: Chronic Kidney Disease (CKD) is defined as decreased kidney function (estimated as an eGFR<60) for three or more months or the presence of kidney damage indicated by a urinary albumin excretion of ≥30 mg/day). 

 

• Pathophysiology: The pathophysiology of CKD is variable based on the underlying condition. Two common etiologies are diabetic nephropathy and hypertensive nephropathy. Diabetic nephropathy is a result of chronic hyperglycemia which results in the glycosylation of the basement membrane and plasma hyperfiltration. This ultimately results in glomerular damage. Hypertensive nephropathy is a result of long standing arterial hypertension and increased capillary hydrostatic pressure in the glomeruli as well as ischemic glomerular damage. 
• Etiology:  Conditions that can cause chronic kidney disease include diabetic nephropathy, hypertensive nephropathy, glomerulonephritis, and polycystic kidney disease. CKD stage is used to guide the management and risk stratify for major complications of CKD such as all-cause mortality, cardiovascular mortality, and progression of kidney disease. . Appropriate staging includes cause of disease, eGFR level, and category of albuminuria. Decline in kidney function is typically asymptomatic. However, when a patient reaches ESRD (eGFR<15) they may show signs such as uremia, electrolyte imbalances, volume overload, and bone disease. 
• Epidemiology: With an aging population and a rise in the incidence of diabetes, CKD and ESRD are becoming increasingly prevalent diagnoses in the United States. The prevalence of ESRD reached 746,557 in 2017 with an increase in incidence by 2.3% from 2017 to 2018. Data from the United States Renal Data System reported a rise in ESRD patients receiving hemodialysis from 84,537 to 112,818 between the years of 2000-2018. Medicare spending for ESRD patients increased from $36.1 billion in 2009 to $38.7 billion in 2018. 

1. Patient Presentation

• Case: Our patient is a 60 year old right-hand dominant female with a past medical history of diabetes, hypertension, hyperlipidemia, and CKD with an eGFR of 20. She has no surgical history and has a family history of heart failure and diabetes. She does not currently work, drinks around 2 glasses of wine a week, and quit smoking 10 years ago. Her current medications include atorvastatin, lisinopril, and aspirin. 

 

1. Diagnosis

• History: H&P of a patient referred for access creation should elicit hand dominance and work history because they can affect where the fistula or graft should be positioned. It is especially important to note any previous access procedures, prior central lines, pacemakers,  thoracic surgeries, or other venous system procedures. A history of chronic infections, immunosuppression, skin diseases, history of stroke, and extremity weaknesses may also affect choice of procedure. 
• Physical Exam and Imaging: discussed in preop assessment section.

 

1. Treatment (Medical/Surgical)

• Non-temporary treatment options include kidney transplantation and dialysis (requires AV Fistula creation, AV graft creation, or peritoneal dialysis access placement). 

 

1. Indications for surgery:

• The treatment of choice for ESRD is kidney transplantation as it provides a higher quality of life and a lower mortality risk for patients when compared with dialysis. 
• Patients who are unable to receive a transplant have a choice between hemodialysis through a hemodialysis catheter, AV Fistula, AV graft, or peritoneal dialysis based on various patient-specific factors. 
• The SVS’s clinical practice guidelines and the National Kidney Foundation - Kidney Disease Outcomes Quality Initiative (NFK-KDOQI) guidelines align in their recommendation to refer patients to a vascular access surgeon for permanent hemodialysis access when their creatinine drops below 25 mL/min. So for our patient, her GFR of 20 warranted a referral to vascular surgery.  
• Early access placement, ideally more than 4 months before the initiation of dialysis, decreases the risk of sepsis and death. This has been attributed to a decreased need for the use of central venous catheters for temporary hemodialysis access.

 

1. Preop Preparation: 

• The first step in a successful permanent AV access placement is a thorough preop evaluation.
• Comorbid conditions impacting access patency rates include age, diabetes, peripheral vascular disease, smoking, hyperparathyroidism, and anemia. 
• Comorbidities: 

• Age, Diabetes, and Smoking have been more extensively studied than others. Retrospective observational studies have shown that smoking increases both early and late failure of AV access. ESRD patients who are smokers should be counseled on smoking cessation and referred to a tobacco cessation program before their AV access procedure. 
• Studies regarding age and its effects have also been largely retrospective observational studies but with conflicting results. A meta-analysis of 13 studies by Lazarides et al. looked at dialysis outcomes in elderly patients and found a higher rate of radiocephalic AV access failure in elderly patients compared with the non elderly. Additionally this analysis found a statistically significant higher rate of brachiocephalic AVF patency compared to radiocephalic access and no statistically significant difference in AVG placement within the elderly population. In conclusion, for elderly patients, upper arm brachial-cephalic AVF or AVG is the preferable access placement site when compared to a distal radial-cephalic AVF. 
• For patients with DM, studies have suggested an increased long term risk of thrombosis and arterial steal.  Taking inflow as distal as possible decreases the risk of steal syndrome. 

 

1. Surgical steps (relevant images can be found in Rutherford Chapter 175):

 

Autogenous Access Steps 

 

1. The selected artery and vein are identified and dissected. 
2. The distal end of the vein is transected. Side branches are identified and ligated to maximize flow into the vein and prevent delayed maturation.
3. Prior to clamping the artery, systemic heparin may be considered. Alternatively, the artery may be clamped and flushed with heparinized saline. 
4. An arteriotomy of  4 to 6 mm is made. Limiting the length decreases the incidence of arterial steal 
5. An end to side AV anastomosis between the end of the vein and side of the artery is performed using a 6-0 or 7-0 monofilament nonabsorbable (prolene) suture. The anastomosis is flushed just prior to completion. An end to side vs side to side anastomosis has been shown to decrease the risk of venous hypertension. 
6. After the anastomosis is completed, remaining side venous branches are identified and ligated through the main incision. Depending on practice style, stable incisions may be done to ligate additional venous branches not accessible through the main incision. This final step increases flow into the main venous segment and promotes maturation. 

 

Autogenous Access with a Transposition

 

1. If a transposition is required, a one-stage or two-stage technique may be utilized. The benefit of a one-stage technique is the need for only one procedure. The benefit of the two stage procedure is being able to assess whether the vein will mature and be usable. Two stage procedures are recommended for small veins <4 mm. 
2. If a two stage procedure is selected, the first stage consists of creating the arterio-venous fistula. 
3. The second stage , the transposition,  is performed 4 to 6 weeks later. A superficial tunnel is created. The venous limb of the fistula is transected and passed through the tunnel. A new anastomosis is created between the two ends of the venous limb of the fistula. 
4. Alternatively, a superficialization of the fistula may be performed. The vein is exposed, side branches ligated, and the vein is mobilized superficially by approximating the subcutaneous tissue below the vein. The vein is transected and mobilized proximal to the anastomosis. A tunnel is created in the subcutaneous tissue. The vein is then passed through the tunnel and once again 

 

Prosthetic Access

 

1. A 6 mm PTFE graft is the graft of choice for an AV graft creation. A tapered graft (4-6mm) should be considered to decrease risk of steal
2. The artery and vein selected for use are identified and dissected. 
3. Subcutaneous tunnel is created using Gore Sheath, the Noon, or the Kelly-Weck tunneler. 
4. The graft is first anastomosed to the vein in an end-to side fashion using a 6-0/7-0 monofilament suture. The venotomy should ideally be made to optimize venous outflow and prevent any turning or twisting of the vein. Systemic heparin is administered to prevent arterial occlusion. The inflow artery is clamped and arterial anastomosis is completed in a similar fashion. Unlike the autogenous access procedure, the arteriotomy does not need to be strictly limited to 4 to 6 mm as the graft size will limit arterial steal.

 

1. Postoperative care: Postop Care and Evaluation of fistulas and grafts revolve around assessing maturation

• AV fistulas generally can take up to 12 weeks to mature whereas AV grafts are ready in 2 weeks. 
• Patients who receive an AV fistula should be assessed by the vascular surgeon 2 weeks post-op, for patency and any early surgical complications such as infection, nerve compression, ischemia, steal syndrome, or extremity swelling. 
• Around 4-6 weeks, the fistula should be evaluated for maturity by using a duplex ultrasound to assess diameter, depth, flow through the fistula, and length of access. 
• Physical examination for maturity should include feeling for a thrill and pulse, evaluation of the body with the optimal length being 6 to 10 cm, and evaluation of the depth ideally within 1 cm of the skin surface. 

 

1. Patency:

• Primary patency is the interval from time of access placement to any intervention required to maintain or reestablish patency. 
• Primary assisted patency is the interval time from access placement to maintenance of access patency and includes surgical or endovascular interventions needed to maintain functionality of a patent access as long as it is not occluded. 
• Once a conduit gets occluded, you move on to measuring secondary patency, which is the interval time from time of access placement to access abandonment. To learn more about this, listeners can check out the section  “time of measurement of patency” in the SVS reporting standards for hemodialysis access.
• The DOPPS study indicated an improvement in AVG primary patency with calcium channel blockers, AVG secondary patency with aspirin, decreased AVG primary patency with warfarin, and improvement in AVF secondary patency with ACE inhibitors. 

 

1. Complications:

• There are a multitude of complications that can arise and affect the patency of the AV fistula or graft. In fact, a large portion of the rise in costs during the transition from CKD to ESRD can be attributed to hospitalizations for AV access failures, revision procedures, repeated access placements, and thrombectomies. 
• Primary AVF failure is defined as an AVF that fails within three months of use or has never been usable for dialysis. Radio-cephalic fistulas have the highest failure rate and are commonly caused by anatomic problems or lesions that were preexisting or arose after the procedure.
• Thrombosis: Hemodynamic changes and flow disturbances can cause intimal hyperplasia primarily at the outflow anastomosis in an AVG and anywhere along the outflow vein in an AVF. Another factor that can contribute to intimal hyperplasia is repeated puncture of the fistula or graft. Intimal hyperplasia can ultimately lead to stenosis and thrombosis. 
• Infection: Infection is the second most common cause of loss of access patency, accounting for 20% of cases. Some of the risk factors for infection include the presence of AV grafts, diabetes, increased age, and repeated cannulation.
• Pseudoaneurysm: Repeated cannulation in the same area of access can result in the formation of a pseudoaneurysm which is a disruption of the vessel wall with a collection of blood contained by fibrous tissue. Pseudoaneurysms have a risk of rupture and infection.
• Dialysis Access Steal Syndrome: Due to the increased blood flow through the AV access, there can develop a decrease in blood flow to the distal extremity. Clinical features of steal syndrome include hand pain, diminished sensory or motor function, or coolness. Risk factors include previous access procedures, diabetes, PAD, CAD, a history of steal syndrome, and female gender. Steal syndrome can lead to permanent neurological damage to the extremity if not dealt with in an expeditious manner.
• Venous Hypertension: Venous HTN commonly occurs due to central venous stenosis primarily caused by chronic endothelial trauma from a previous catheter placement. Venous HTN impacts access patency and function and can lead to severe edema.

1. Top Asked Questions:

 

1. What are the rules of 6’s? 

• The rule of 6s is an easy way to evaluate the maturity of a fistula. Six weeks after the AV fistula is created, the fistula should be able to support a blood flow of 600ml/min, be at a maximum of 6mm from the surface, and have a diameter greater than 6mm

 

1. What are the indications for choosing an AV graft vs. an AV fistula vs a temporary catheter?

• Indications for choosing AVF:

• Preferred over AVGs due to their superior patency rates if the patient's vascular anatomical characteristics such as diameter and depth are deemed appropriate through physical examination and vascular mapping via ultrasound.
• Less chances of infection compared to AVGs and temporary catheter. 

 

• Indications for choosing AVGs: 

• Once native fistulas in the non dominant arm have been exhausted you move on to the consideration of AVGs. 
• If a patient’s vascular anatomy is inadequate for AVF placement.
• If a patient requires an expedited catheter removal, AVGs can be considered to avoid longer maturation time of AVF 
• Older age and smaller vein size have been associated with appropriateness of using AVG or AVF 

 

• Indications for choosing temporary catheters include the following: 

• Patient is in need of dialysis but has not yet received an AVF/AVG or their AVF/AVG is not ready for use 
• AVF/AVG/Peritoneal Dialysis with complications and temporarily not able to be utilized 
• Patient requires dialysis but has a transplant confirmed in <90 days 
• Acute need of dialysis without indications for permanent HA access placement

 

1. How long do AV Fistulas and AV grafts typically last? 

• Autogenous AV access has better primary and secondary patency rates compared to prosthetic AV access (refer to patency paragraph #9 above for definitions of patency). 

 

Patency Measure

Autogenous Access

AV graft

1-year Primary Patency

43%-85%

40%-54%

2-year Primary Patency

40%-69%

18%-30%

1- year Secondary Patency 

46%-90%

59%-65%

2-year Secondary Patency

62%-75%

40%-60%

1. Apart from an AV Graft and AV Fistula, what is another method of permanent dialysis? 

 

• Peritoneal dialysis (PD) is an alternative method of dialysis that utilizes the peritoneum as a membrane for fluid dissolution and exchange.
• PD is as effective as hemodialysis access (HA) with the only absolute contraindication being a lack of peritoneal membrane. However, there are other factors to consider when choosing between PD and HA for dialysis access. Medical considerations include previous peritoneal scarring, adhesions, or hernias. Additionally, because PD is performed by the patient and not in a dialysis center, it is vital to assess any patient specific factors (physical, social, environmental) that could prevent them from adhering to their dialysis regimen. 
• When working up a patient for dialysis access, PD should be considered as a potential option. If a patient is deemed suitable for PD, it can provide a much higher quality of life than HA. PD can be performed from the home relieving the patient of visits to a dialysis center multiple days during the week. PD can also be performed overnight while the patient is asleep and does not require needle sticks. 

 

References: 

 

1. Misskey, J., & Hsiang, Y. (2015). The First Arteriovenous Fistula: A History of Hemodialysis Access and a Forgotten Pioneer. In Journal of Vascular Surgery (Vol. 61, Issue 6, p. 81S). Elsevier BV. https://doi.org/10.1016/j.jvs.2015.04.156

 

1. Polo JR. Kenneth Charles Appell, M.D.: the surgeon who performed the first radiocephalic fistulas for hemodialysis. Am Surg. 2006 Feb;72(2):172-3. PMID: 16536251.

 

1. Annual data report. USRDS. (n.d.). Retrieved February 21, 2022, from https://adr.usrds.org/2020/end-stage-renal-disease/1-incidence-prevalence-patient-characteristics-and-treatment-modalities 

 

1. Chopra, V. Central venous access devices and approach to device and site selection in adults. In T. Post (Ed.). UpToDate, Waltham, MA (accessed on February 20, 2022): UpToDate.

 

1. Oliver, M., Quinn, R. Approach to the adult patient needing vascular access for chronic hemodialysis. In T. Post (Ed.). UpToDate, Waltham, MA (accessed on February 20, 2022): UpToDate.

 

1. Woo, K. Arteriovenous fistula creation for hemodialysis and its complications. InUpToDate. UpToDate, Waltham, MA. (Accessed on February 22, 2022) 

 

1. Woo, K. Arteriovenous graft creation for hemodialysis and its complications. In T. Post (Ed.),UpToDate. UpToDate, Waltham, MA. (Accessed on February 22, 2022).

 

1. Aitken, E., Jackson, A., Kearns, R., Steven, M., Kinsella, J., Clancy, M., & Macfarlane, A. (2016). Effect of regional versus local anaesthesia on outcome after arteriovenous fistula creation: a randomised controlled trial.Lancet (London, England),388(10049), 1067–1074. https://doi.org/10.1016/S0140-6736(16)30948-5

 

1. Lazarides, M. K., Georgiadis, G. S., Antoniou, G. A., & Staramos, D. N. (2007). A meta-analysis of dialysis access outcome in elderly patients.Journal of vascular surgery, 45(2), 420–426. https://doi.org/10.1016/j.jvs.2006.10.035

 

1. Pisoni, R. L., Gillespie, B. W., Dickinson, D. M., Chen, K., Kutner, M. H., & Wolfe, R. A. (2004). The Dialysis Outcomes and Practice Patterns Study (DOPPS): design, data elements, and methodology.American journal of kidney diseases : the official journal of the National Kidney Foundation,44(5 Suppl 2), 7–15. https://doi.org/10.1053/j.ajkd.2004.08.005

 

1. Sidawy AN, Gray R, Besarab A, Henry M, Ascher E, Silva M Jr, Miller A, Scher L, Trerotola S, Gregory RT, Rutherford RB, Kent KC. Recommended standards for reports dealing with arteriovenous hemodialysis accesses. J Vasc Surg. 2002 Mar;35(3):603-10. doi: 10.1067/mva.2002.122025. PMID: 11877717.

 

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