We talk with Vascular Access Surgeon Ari Kramer about AV Fistula and Graft Maintenance in dialysis patients from creation to long-term care, as well as tips and tricks for treating stenoses.

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SHOW NOTES

In this episode, vascular access surgeon Dr. Ari Kramer and our host Dr. Chris Beck discuss the creation, management, and salvage of AV fistulas and grafts.

Dr. Kramer describes the referral patterns that lead dialysis patients to his practice, citing the need to coordinate dialysis care around a common surgical practice. He works closely with nephrologists and dialysis centers to ensure quality of care and streamlined patient management. During an initial workup, Dr. Kramer includes a physical assessment and an echocardiogram to establish a baseline.

The doctors discuss the pros and cons of using AV fistulas versus grafts. While AV fistulas are autogenic and carry a lower risk of infection, there is a risk that these may not mature. On the other hand, AV grafts are fully matured but they carry a higher risk of infection and require a higher intervention rate. Dr. Kramer emphasizes the importance of understanding a patient’s cardiac performance and history before selecting a method of AV access. He also schedules periodic follow-up appointments to ensure that the access site reaches maturity, which is evaluated by the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines.

Dr. Kramer walks us through devices and procedures for angioplasty, stent placement, and drug coated balloon placement. Finally, he addresses strategies for managing re-stenosis and considerations for patient preferences regarding surgical revision.

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RESOURCES

Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guideline for Vascular Access: 2019 Update: https://www.ajkd.org/article/S0272-6386(19)31137-0/fulltext#secsectitle0720

American Society of Diagnostic and Interventional Nephrology (ASDIN): https://www.asdin.org/page/A2

Kidney Academy (use code “backtable21” for free access): https://www.kidneyacademy.com/