II Facoltà di Medicina e Psicologia “Sapienza” Università ... · creazione e gestione degli accessi vascolari per emodialisi Roma 6-7-8 Maggio 2013 . Accessi distali: Microchirurgia

II Facoltà di Medicina e Psicologia

“Sapienza” Università di Roma Cattedra

di Nefrologia

VI Corso teorico-pratico

NEFROLOGIA INTERVENTISTICA

Attualità in tema di programmazione,

creazione e gestione

degli accessi vascolari per emodialisi

Roma

6-7-8 Maggio 2013

www.nefrologiainterventistica.com

Accessi distali: Microchirurgia

e Lipectomia (nell’obeso)

Pierre BOURQUELOT

Paris

Accessi distali

Microchirurgia

- Adults

- Children

Lipectomia

Microscope Zeiss

OPMI Vario/S88 System

Learning curve: Rat is the best animal for training

5

Microsurgical Instruments

6

Adults

Acland’s clamps 8 – 9/0 ethilon sutures

Children

Heifetz micro-clamps 10/0 ethilon

Side to End Anastomosis

9

Radial Cephalic AVF

Distal AVF (< 10 kg)

Preventive Hemostasis

Using

- Esmarch bandage

- and pneumatic tourniquet

Limits artery dissection, avoiding artery

spasm

12

Distal Ulnar-Basilic AVF (tourniquet)

After release of tourniquet

Distal Cephalic or Basilic AVF

82-years man 14-years boy

Bourquelot JVS 2011

Accessi distali

Microchirurgia

- Adults (Results)

- Children

Lipectomia

Microsurgery - Adults

Prospective study, 101 adults

consecutive patients operated between

January and October 2005 for First

arteriovenous angioaccess creation.

2 Groups:

- 76 patients (Group A) = non yet dialysed

- 25 patients (Group B) = CVC.

Not yet dialysed Pts Access at the beginning of dialysis

74%

13%

10% 3%

Radio-Cephalic

Brachio-Cephalic

Brachio-Basilic

CVC

N = 76

Not yet dialysed Pts

Access after 6 months of dialysis

74%

9% 13%

4%

n=23

Radial Cephalic

Brachial Cephalic

Brachial-Basilic

CVC

Distal AVF

CVC dialysed patients

Access after 6 months

52%

13%

18%

13%

4%

Radial-cephalic

Brachial-cephalic

Brachial-basilic

CV Catheter

PTFE

N=25

Distal AVF

4 CVC after 6 months

(groups A and B)

1 patient, 89 y., major artery

calcifications

1 patient, 61 y., major distal ischemia

2 patients, non-matured 2nd AVF.

Obese pts sub-group: 13 Pts

BMI > 30 (n)

81

4Radiocephalic

Brachiocephalic

Brachiobasilic

CV Catheter=0

Superfic.: 6/8

Adults – Patency rates (early failures included)

Radio

Cephalic

Primary 3 m. 78%

Primary 1 y. 63%

Secondary

n = 68 1 y. 91%

Accessi distali

Microchirurgia

- Adults

- Children (Results)

Lipectomia

Angioacces in children Without microsurgery

USA

4%

89%

Graft AVF CVC

With Microsurgery

France (Paris)

0%

70%

30%

Graft AVF CVC

Microsurgery - Children

Prospective study: 127 children

operated consecutively during a 6 year-

period of time.

131 autologous AVF.

Mean age: 8 y. (0.6 to 15).

Mean weight: 26 kilos (6 to 70).

131 AVF – 127 Children

76%

2%

5% 15%

2% Radiocephalic

Ulnobasilic

Brachiocephalic

Brachiobasilic

Femoral veinsuperficialisation

Distal AVF = 78%

Children – Patency rates (initiall failures included)

Radio

Cephalic

Primary 3 mos 97%

Primary 1 y. 63%

Secondary 1 y. 95%

Evolution - Children

6 Pre-emptive kidney transplants

95 Curative kidney transplants

- Mean delay after AVF creation = 817 days

- Mean age = 9 y.(2 to 19)

6 Deaths during follow-up.

Bau…Nino, 8kg

Hyperoxaluria

Born 12/2001

PD 12/2002

Radial AVF 01/2003,

Hemodialysis 10/2003

Re-anast. 03/2004

Kidney & Liver Transpl. 06/2005

Accessi distali

Microchirurgia

- Adults

- Children

Lipectomia

6 mm

Duplex ulltrasound

On-line Superficialisation

Tunnel-Superficialisation

1 : skin

2 : adipose

tissue

3 : fascia

superficialis

4 : vein

Lipectomy

Lipectomy

1 : skin

2 : adipose

tissue

3 : fascia

superficialis

4 : vein

Lipectomy

1 : skin

2 : adipose

tissue

3 : fascia

superficialis

4 : vein

Incisions

Incisions

Pre-vein dissection

Adipose tissues resection

Removed fat pads

After tourniquet release

Drain and skin suture

3-year post-lipectomie

Pre- and post-operative

duplex ultrasound 49 patients Pre-Lipectomy Post-Lipectomy

Depth

(mm)

8 ± 2 3 ± 1

Diameter

(mm)

6 ± 1 8 ± 2

Flow rate

(mL/min) 755 ± 150 794 ± 215

Bourquelot et al.JVS 2009

3-year patency after Lipectomy

49 pts

88 %

63 %

Bourquelot et al.JVS 2009

Conclusion

Microsurgery allows for high rate distal

AVF creation in incidents patients ,

adults and chidren, with few early

failures, excellent long-term patency

rates and very few ischemic

complications.

Lipectomy is efficient for

superficialization.

[email protected]

II Facoltà di Medicina e Psicologia

“Sapienza” Università di Roma Cattedra

di Nefrologia

VI Corso teorico-pratico

NEFROLOGIA INTERVENTISTICA

Attualità in tema di programmazione,

creazione e gestione

degli accessi vascolari per emodialisi

Roma

6-7-8 Maggio 2013

www.nefrologiainterventistica.com