ワークショップ A 【VAIVTのPatencyとは】 VAIVT …...Before 2012 APRIL (240 cases) ※：LOGRANK P

第22回バスキュラーアクセスインターベンション治療研究会ワークショップＡ

2017年3月4日（土） 9：00～10：00都市センターホテル 第1会場 コスモスホール

ワークショップ Ａ 【VAIVTのPatencyとは】

VAIVTのPatencyを保険の制約によって3か月以上延ばす努力と工夫

医療法人 心信会池田バスキュラーアクセス・透析・内科

池田 潔

Today Topics

#1 VAIVT Results

#2 Expansion Technique Examination : Animal model

#3 DW Consideration

#4 Others

Table1 : The Ratio of the number of VAIVT required within 3 months

PeriodThe number of

cases

The number of VAIVT within 3 months

(number of medical service fee)

Ratio(％)

AVF

2010/9/1 - 2012/3/31 199 56 28.1

2012/4/1 - 2013/3/31 179 34 19.0

2013/4/1 - 2013/12/31 146 39 26.7

2014/1/1 - 2014/12/31 286 131 45.8

2015/1/1 - 2015/12/31 271 66（36） 24.3（13.3）

2016/1/1 - 2016/12/31 294 60（40） 20.4（13.6）

AVG

2010/9/1 - 2012/3/31 137 44 32.1

2012/4/1 - 2013/3/31 98 16 16.3

2013/4/1 - 2013/12/31 64 20 31.2

2014/1/1 - 2014/12/31 96 48 50.0

2015/1/1 - 2015/12/31 92 12（7） 13.0(7.6)

2016/1/1 - 2016/12/31 86 21（15） 24.4(17.4)

Period : 2010.9-2016.12

Fig.1 : AVF Patency rate 2003-2010

(%)

0

10

20

30

40

50

60

70

80

90

100

0 200 400 600 800 1000 1200

Patency ratio

Patency period

(%)

(days)

Ave. atm Ave. balloon size

A 6.84±2.11 4.62±0.68

B 7.65±3.06 5.18±0.72

C 9.09±9.92 5.31±5.37

〔mean±SD〕

―A group：NSE (n: 63)―B group：Angio Sculpt (n: 45)―C group：DORADO (n:202)

A vs B (n.s.)A vs C (n.s.)B vs C (p<0.01)

Fig.2 : Comparison of Patency period

0

20

40

60

80

100

0 200 400 600 800 1000

After 2012 APRIL (140 cases)

Before 2012 APRIL (240 cases)

(Days)

(%)

※

※： LOGRANK P<0.001

(Kaplan-Meier method)

No.9Ikeda Vascular Access/Dialysis/Internal Medicine Clinic no.9

Fig.3 : Primary Patency of VAIVT in AVF Cases

0

20

40

60

80

100

0 200 400 600 800 1000

After 2012 APRIL (140 cases)

Before 2012 APRIL (240 cases)

※： LOGRANK P<0.05

※

(Days)

(Kaplan-Meier method)

(%)

No.10Ikeda Vascular Access/Dialysis/Internal Medicine Clinic no.10

Fig.4 : Secondary Patency of VAIVT in AVF Cases

Today Topics

#1 VAIVT Results

#2 Expansion Technique Examination : Animal model

#3 DW Consideration

#4 Others

頻回低圧拡張法 実演

第2回九州バスキュラーアクセスライブフォーラムにて（2014.11.9）

DSA

狭窄部位

Point A

pre 3atm 8atm

New Low Pressure Technique (LPT)

①New Low Pressure Technique (LPT) isan attempt to maximize blood flowrate when using maximum pressure isnot an option.②In this example of LPT we take a

balloon rated to 15atm but only usingit up to its nominal pressure of 6atm.Beginning at 1atm and expanding

and contracting the balloon 20 to 25times a minute while increasing thepressure by 1 atm every minute upto the nominal pressure of 6atm.Total time is 6 minutes and in somecases slight more time.

Pre PTA

2atm x 30sec

3atm x 30sec

4atm x 30sec

New Low Pressure Technique (LPT)

③Balloon expansion is graduallyincreased during the first 5 minutesto full vein size in the final minute.④This method applies to all balloonpressures and is used accordinglybased on the balloon's rated pressureand nominal pressure.

One of the goals of this technique is toachieve full expansion at low pressure.

6atm x 30sec

7atm x 30sec

8atm x 30sec

Post PTA

Super-non-compliant balloon vs Others

Super-non-compliant Balloon

As shown in the figure, group A, using a super non-compliant balloon eliminates the occurrence of dog bone phenomenon. Vein damage is also avoided because the balloon is limited in its expansion.

7atm

Dog-bone phenomenon

As shown in the figure, group B, when using a semi-compliant balloon that looks like it is being bitten by a dog, causes intimal injury and the main objective is not achieved due to the fact that the balloon expands beyond the optimal size.

6atm

【Conclusions】

#1 Dog-bone phenomenon can be avoided by using a super-non-complianｔ balloon.

#2 LPT, using nominal pressure, resulted in very good patency period.

#3 LPT prevents intimal injury and vein damage.

【Subject & Methods】

Experimental model, Japanese white rabbit♂（3-4kg）（n=6）

Ikeda method (n=3), High pressure single extended (n=3)

－－－－－－－－－－－－－－－－－－－－－－－－－－－－1. Make an arteriovenous anastomosis using side-to-side technique between Right common carotid

artery and Right external jugular vein.

2. After 2 weeks, make a stenosis to the venous heart side using Sugita clip.

3. Using a diameter 3.5mm Sugita clip and then make a stenosis about 65%.

4. After 4 weeks, remove the Sugita clip.

5. High pressure single extended type (20atm 30seconds) using 10mm Conquest balloon. Extended by Ikeda method.

6. After 4 weeks in PTA, terminate for pathological examination

4 weeks

Side-to-side anastomosis to Right common carotid artery and Right external jugular vein

Make an AVF Make a Stenosis

Using 5mm Sugita clipMaking a stenosis about 65%

Remove a clip Terminate

2 weeks

PTA

Extend by 10mm balloon(20atm 30seconds)

4 weeks

＜Ikeda method＞＜High pressure

single expansion＞

Fig.8

Make an AVF, put a Sugita clip on the heart V-side for 2 weeks

After 4 weeks, PTA

Terminate after 4 weeks

Ikeda method15-01_7HE×20

15-12_10HE×20

High pressure single expansion15-02_9HE×20

15-13_9HE×20

intimal thickening

invasion of the smooth muscle

intimal thickening

Today Topics

#1 VAIVT Results

#2 Expansion Technique Examination : Animal model

#3 DW Consideration

#4 Others

VAIVT：Docter decides devices and therapy’ method

VA management: Periodical check using ultrasound

Strategy to extend patency period

【Background 】

※Management using ultrasound to evaluate VA condition does not contribute to extend primary patency period.

※ Determining Hemodialysis Patient’s DW in dialysis unit is very important.

【Background 】

#1 CTR#2 Blood Pressure#3 Measurement of IVC after hemodialysis

#4 BCM examination

ＤＷ Determination Factors

<Input of Personal information>1) Height2) Weight3) Age4) Sex

BCM（BodyCompostionMonitor）

-3

-2

-1

0

1

2

3

Ａ値 Ｂ値

mean±SE

PTA(-)(n=261)+0.13Kg

PTA(+)(n=139)-0.96Kg

P=NS

Fig.10 : Comparison of BCM results （DW－Ideal BW）PTA(-) vs PTA(+)

2015；74.2%

2014；39.6%

p:ns

Patency ratio

【Results】

Fig.11 : Primary Patency Period

DAYS

Today Topics

#1 VAIVT Results

#2 Expansion Technique Examination : Animal model

#3 DW Consideration

#4 Othersa) Milking Method

【Pressure ＶＡMassage（PVM）】

～Points～

PVM is done by pushing blood to stenotic area using both hands.

①One hand stops shunt flow on the down flow side.

②The other hand presses vein from up flow side.

This method stretches stenotic area.

【Results 1】

1.46

0.63

1.16

1.89

0.570.94

0

1

2

3

4

5

6

7

狭窄径（mm） FV（mL/min） RI PI

1.57

0.420.57

2.04

0.33 0.41

0

1

2

3

4

5

6

狭窄径（mm） FV（mL/min） RI PI

490

610

420

480

（+29.5%）

（+24.5%）

（+9.5%）（+19.5%）

（+29.9%）

（+14.3%）

（+21.4%） （+28.1%）

Results after examination.

Case1 Case2

Diameter (mm) Diameter (mm)

Before PVMAfter PVM

Fig.12 : Ultrasound Examination Data

58.6

111

0

20

40

60

80

100

120

VAマッサージ開始前 VAマッサージ開始後

70

124

0

20

40

60

80

100

120

140

VAマッサージ開始前 VAマッサージ開始後

n=6 n=4

Case1 Case2

This method contributed to 3 month rule.

VA massage before the start VA massage after the start VA massage before the start VA massage after the start

【Results 2】

Fig.13 : Patency period (days)

#1 Existing devices limit potential for extending patency period.

#2 Existing devices have potential for extending patency period if expansion technique is used.

#3 The accuracy of DW management helps to avoid VA trouble.

#4 VA massage is possible on vein close to surface..

【 Conclusions】

保険制約の中で可能な事

１）拡張方法の考慮

２）透析状況の把握