Slide 1

Thank you very much Mr Chairman. I’m probably the single surgeon who between all these nephrologists, so I shall be very careful, of course. But without vascular access it’s very difficult for you to do haemodialysis so I’m going to talk about vascular access guidelines.

Slide 2

So, this is I think a minute or two we have looked into vascular access as the main issue. As you probably can see in the next time that we have only very few level evidence for vascular access.

Slide 3

We looked at certain aspects and then we did some surveys on certain aspects of vascular access and in particular have looked at these different things patient referral, pre-operative evaluation, strategies, role of nurses and surveillance, diagnosis of stenoses, treatment of stenoses, central venous obstructions, access-induced ischemia and last I think because we think that permanent vascular access is more important to these patients than a catheter at last we looked at central venous access and complications.

Slide 4

At first timely referral, we think that an early plan for venous preservation, preservation of the veins is very, very important in patients that have renal failure and particularly it’s important to do this preservation because we think that fistulae are very important for patients and it is better to put in fistulae instead of grafts, so venous preservation in a very early time is important.
The second part is that every renal failure patient should start with a functioning vascular access and of course, you should that’s normal but still this is very important to think about.
The third one in the first guidelines is that we have looked at the referral to the nephrologist and/or vascular  surgeon at a very early phase of stage 4 kidney failure and this in particular in diabetic patients is very important because you need time to prepare vascular access.
In these patients with very poor vessels you can imagine that you have more time to get this vascular access functioning and I’ll show you in a minute.

Slide 5

Early referral is important because if you have a very late referral, they usually will have more complications and can even have higher mortality. If you look at this publication of Ravani you see, if you have late referral, the survival is late and usually this is due to the need of catheters in these patients that have been referred fairly late. Again, if you look at the outcome of your vascular access in patients that have been referred very late, you see this outcome of fistulae in terms of failure is worse in patients that have been referred late to the nephrologist or to the surgeon for vascular access. Of course, in patients with cardiovascular disease also your outcome is worse as compared to patients without that.

Slide 6

Another issue what I think we thought as a group was very important to look at clinical evaluation before vascular access creation. We think that physical examination is important but it should be added to that with an objective measure of vessel quality and vessel diameter with the means of ultrasonography. From the literature you can find a lot of data that points to the better outcome of vascular access in terms of fistula use, if you use ultrasonography before access creation at certain parameters that can predict better outcome of fistula creation and even if we look at diameters with the scanning of the vessel before operations, it is really correlated to the flow to the fistula and flow’s also associated with better outcome.

Slide 7

This is probably the most important aspect of these guidelines as you look at strategies for access creation and of course, every access should provide flow that is enough to have adequate dialysis therapy. In addition to this, we think that the creation of autogenous fistulae is preferred to the implantation of grafts. I will show in a minute that it gives a better outcomes in terms of morbidity, mortality and as a last choice you can choose catheter implantation but these are usually associated with a higher risk of mortality and morbidity. The access should be created in the upper extremity instead of the lower extremity. This 3.5 guideline is very important. You should look at your maturation don’t let it go, look at the maturation of your fistulae. Of course, you can have some impact on maturation by intervention and you should follow this.

Slide 8

A study from Polkinghorne looking at the survival according to the method of vascular access as seen here, if you use a catheter, the survival of patients is really significantly worse as compared to patients that use fistulae or even grafts and this is highly significant.

Slide 9

Looking at maturation we know that in particular, fistulae have a risk of no maturation, people have to wait for the permanent vascular access and usually you have to put in catheters in this patient group but you can follow this maturation very easily looking at flow and flow is really correlated with maturation. If your flow after operation is low, you can expect that after 6 weeks or even 3 months your access is not mature enough and you cannot use it.
Look at your flow at day 1, 1 week, and 6 weeks you can see that it goes up, it’s highly correlated with good maturation and usefulness of your fistula.

Slide 10

An important other aspect in vascular access is looking at event complications in terms of occlusion or low flow or inadequate dialysis through malfunctioning of your vascular access and that is easy to perform because all these patients have a 100% follow up. They can be looked for at the dialysis department very easily by the nurses, by physical examinations and see if there’s any change in vascular access properties, murmurs or trills but maybe it’s better to do an objective monitoring of the access function by measuring flow. If you measure flow, particularly if you use grafts, there is a certain cut off value below which the chance of occlusion or thrombosis is very high as we can see here. Really flow is a better predictor as compared to venous pressure, so we think that measuring flow is the most important thing to do. If you measure flow and you do pre-emptive intervention, you can see that you can have a better survival in these cases of fistulae compared to the fistulae the patients that haven’t had this monitoring.
So, one of the guidelines, guideline 5 we think that monitoring is mandatory to improve the outcome of your vascular access.

Slide 11

Stenoses treatment is another important issue. These patients are really occurring stenosis development in their accesses. We know that that is going to happen so you have to look at it but you also have to look at what is the best treatment for this. If you suspect by physical examination or by flow measurements stenoses, then you should go on with imaging and also with pre-emptive intervention. This imaging should be performed very soon within a certain time period, send these patients to the radiologist, and try to perform an intervention percutaneously that for the patient is very convenient and for the access ---- survival. If you have the need for imaging the complete outflow and inflow and we see more and more patients with diabetes with poor vessels, also arterial vessels in your upper arm, there’s more and more need to see also the inflow and then we can try to do magnetic resonance angiography. I have to say that now with this new problem with this fibrosis so this is really disputable of course, this line, we couldn’t change it anymore according to the new literature.

Slide 12

If you find by physical examination or even by flow decline an indication for angiography, you find a high percentage of patients with a positive angiography, so if the flow goes down you see a lot of these patients have really stenoses. With this monitoring you can have a very good accuracy for stenoses for detection.

Slide 13

So, there are really effective measurements, flow measurements to detect stenoses and to send these patients to the radiologist. Pre-emptive intervention should be performed percutaneously or if you don’t have a dialysist in your hospital, you can try to do surgery but it’s more inconvenient for the patient. You have to go to the operating theatre, so we think that pre-emptive intervention is the best. We also could find from the literature that you should do this in one attempt of imaging and intervention in the same session and again, you see that the flow goes up after intervention very significantly and also the outcome of your vascular access in terms of long-term durability is better in patients that have pre-emptive intervention.

Slide 14

Guideline 6.3. Looking at the complete arterial inflow there’s really a very accurate use of magnetic resonance angiography for stenoses detection as you can see here but also with MRA you can very easily detect arterial inflow and also the venous outflow and a particular set of vein area is very good to --- that MRA as compared to other imaging techniques.

Slide 15

Treatment of stenosis and thrombosis guideline 7. For the outflow stenosis we can find very outcomes in the literature by PTA first treatment options. If you have to do treatment of thrombosed vascular access, the same for grafts or fistulae, it depends a little bit on the experience you have, that the surgeon has or if you have a very delicate --- in your department you can chose for either.

Slide 16

So it really is ---  situation if you go to the surgery or to the dialysist, if you look at the meta-analysis there’s probably some more favourable outcome for surgery but it’s really not highly significant, so it depends really on the dedication and the experience of the local radiologist or surgeon.

Slide 17

Central venous obstructions. A lot of these patients have had catheters in the past. You can expect in these patients that you’ve got stenosis and obstruction in that area. If you have this and these patients get symptoms usually with oedema of the arm, then you have to do angiography of the outflow, complete venous outflow tract. Again, intervention treatment by percutaneous intervention by the ---- is the first option of treatment of central venous obstruction and the outcome usually is good as you can find here after 1 year 3 cohorts of patients have good outcomes.

Slide 18

Ischemia, we see it more and more particularly in diabetic patients. It’s a dreadful complication of vascular access it should be detected in a very early phase because the risk of amputation is of high risk. Clinical investigation is important but you should always do imaging or either with duplex scanning and pressure measurements or angiography. The treatment is really difficult therefore, as angiography is so important, you have to look at the arterial inflow.

Slide 19

If there is any inflow obstruction, you can enhance this by PTA. If you have high flow fistulae but still the phenomenon, you can try to do excess flow reduction or distal revascularisation procedures. But if these all fail you have to close the access and you have to know that if you go to the other extremity, the risk of ischemia developing is even higher as the other sites. So you can foresee these patients going to peritoneal dialysis or catheter use. You can see some results. A lot of publications on this method. If you look at distal revascularisation procedures, a high success ratio and this is also the case for a flow reduction operation where you can have good results with about 90% ischemia relief in these patients with ischemia and also in these patients  ---- is provided.

Slide 20

Central venous access is one of the last guidelines. Of course, if you need access usually in an acute dialysis setting this new fistula or graft then you have to put in a central venous catheter and the percutaneous route should be applied for the acute and chronic catheter and ultrasound is mandatory in these. The internal jugular vein should be the preferred location because the subclavian vein location is at high risk of obstruction about 40-60% of these patients will get obstruction that will give difficulties for future access planning. Of course the jugular vein route can give obstruction but in less percentages. I think we have seen in the literature that long-term catheters are really associated with high risk of infection and should only be used in emergency situations and should be replaced by permanent catheters as soon as possible.

Slide 21

The ultrasound guided insertion gives a very high success rate in terms of number punctures and also the number of complications and particularly --- function is low with  ultrasound guided catheter insertion. So was this really necessary with ultrasound? Of course,  know a lot of new and older people very experienced in doing this without ultrasound but get a lot of problems if you put a catheter in a necrotic artery. So use ultrasound.

Slide 22

Mr Chairman, if I can summarise these guidelines I think that timely referral is very important because we need time to create a permanent access in these patients and particularly we try to put in fistulae because they’re doing better than catheters timely referral usually 3-6 months before start of dialysis treatment. Preoperative assessment and predialysis care is important, try to preserve vessels, look at vessels and do duplex scanning because it gives a better outcome. We prefer autogenous fistulae because they have been proven to have better outcome in terms of morbidity and mortality. Maintenance can be provided by monitoring and pre-emptive intervention. Ultrasound guided catheter insertion via the jugular vein route is mandatory to diminish the number of complications in these patients.

Slide 23

A pre-emptive repair of failing access is important because the outcome of intervention for thrombosed accesses is poor as pre-emptive repair of the failing access. Ischemia treatment remains difficult, it depends on the cause of ischemia and that is really very different in the different patients, a specific treatment should be performed. Angiography is mandatory to look at inflow obstruction and then again, arterial inflow enhancement can be done in cases of high flow and still flow reduction procedures or bypass surgery is advisable and the last is the central venous obstruction formed should be imaged by central vein angiography and together with PTA or --- by intervention diagnosis. Thank you very much.

Slide 24

Chairman: Thank you Jan. So I think there is time for one question. Yes please?

Question: -- Austria. You gave us a lot of good recommendations of when to do a fistula and this is clinical experience in all of us but what I completely missed is the guideline when not to do a fistula. We all have about worldwide 25% of patients only on central venous catheters and 10-30% are on peritoneal dialysis. So where are the guidelines of when to avoid a fistula especially in the cases of severe heart insufficiency or pulmonary hypertension? Please give us a statement on this because this would also be helpful for us.

Dr Tordoir: Yes I take it as a very important issue. If you see and you can take this from my presentation we try to avoid catheters because we think and it has been proven in the literature that they have been associated with a very high morbidity and even mortality, so catheter use we try to avoid it. But I agree with you that in some patients you cannot create vascular access with fistulae and grafts because they have high risk of ischemia as well or heart failure. The problem with heart failure is that we don’t have really evidence on the problem if there’s any risk to create fistulae and grafts of a deteriorating your heart failure in these patients. There’s no evidence for that. Really hardly any literature on that and there arguing has still not ended on these methods. We think still that you should try to go on for an autologous fistula. If you cannot do it in the wrist, then you go in the upper arm.

Chairman: The guideline actually says if it is possible go for a fistula, if it’s not possible then do a graft, if that is not possible do a central vein catheter. I think this is a stepwise approach and we couldn’t go further because there’s no literature on that. Short questions please.

Question: Yes short question --- Brussels, Belgium. I would like to know your opinion about the guideline 6.3 concerning the use of magnetic resonance angiography and the risk especially in patients with CKD stage 4 and 5 to develop a nephrotoxicity fibrosis related to the use of gadolinium agents especially gadiodinomide. What’s your opinion, do you recommend this technique for evaluation?

Dr Tordoir: Of course, the problem is now these guidelines have been developed. Probably one year ago we ended this guideline development and after this we got more and more information in literature that this complication could happen, so now you cannot give any gadolinium anymore pre-operatively or in pre-dialysis patients. I think you should avoid it now.

Chairman: Ok next question short one, also short answer.

Question: --- Los Angeles. You mentioned all kinds of guidelines for access but what might be advisable perhaps if you would consider to develop guidelines for the use of catheters, there are data, published data that outcomes with catheters are no worse than outcomes with fistulae and grafts, if you observe strict sterility guidelines. Maybe it’s high time to develop practise guidelines for utilisation of catheters in an appropriate fashion. I suspect that they would come up with far better outcomes with catheters than what your outcomes are now.

Dr Tordoir: I don’t know of any publications about randomisation between catheters and fistulae. There’s really data on the high morbidity, mortality with catheters in the long-run really so we try to forecast this.

Chairman: I must say that we didn’t do our literature search ourselves. This was done by Cochrane so they delivered all the literature with the evidence levels. We used everything that we got from them. So, that’s all I can say about the methodology that was applied. Ok if there are no more questions. Thank you Jan