Interventionalist Education and Resources Outline

This document is a product of the Interventionalist Subcommittee of the Fistula First Breakthrough Initiative. The outline will be updated as new resources are identified and/or developed.

Goals

1. Acquaint interventionalists with patterns of failure in fistulae, as well as tools, techniques and outcomes for enhancing maturation, maintaining and restoring function to non-maturing, failing and clotted fistulae respectively.

2. Suggest criteria for appropriate use of interventions versus surgical alternatives.

3. Educate interventionalists about limiting catheter use and appropriate use of catheters.
   
   Introduction: Creating AVF in all Eligible Hemodialysis Patients Fistula First Initiative (Video)
   
   Fistula First: National Vascular Access Improvement Initiative (Handout)

Outline

Introduction-importance of fistulae:
Fistula First Interventionalists: Getting Started (Video)

1. Anatomy of fistulae
   
   Interventional Radiology in Fistulae: Introduction (Video)
   

   1. In situ (In progress – Check back soon)

   2. Transposed (In progress – Check back soon)

   3. Gracz (In progress – Check back soon)

   4. Exotic (In progress – Check back soon)

2. Patterns of failure of fistulae

   1. Non-maturation: define (rule of 6’s)
      
      Assessment of the New AVF for Maturity (Video)
      
      Assessment of the New AVF for Maturity (Handout)
      
      Salvaging Immature Fistulae (Video)
      

   2. Mature but failing fistulae

      1. Clinical presentations
         
         Fistulography (Video)
         

      2. Physical exam findings
         
         Fistulography (Video)
         
         Navigating the Vascular “Seas” Self Exam of Access ~ Simplified (Handout)
         
         Assessment of the Mature AVF (Video)
         

   3. Clotted fistulae

      1. Large vs. small to absent clot burden
         
         Fistulography (Video)
         

3. Non-maturation

   1. Definitions
      
      Assessment of the New AVF for Maturity (Video)
      
      Assessment of the New AVF for Maturity (Handout)
      

   2. Angioplasty
      
      Salvaging Immature Fistulae (Video)
      
      Endovascular Presentation of Immature and Dysfunctional AVF’s (Video)
      
      Endovascular Preservation of Immature Dysfunctional AVF’s (Handout)
      
      Non-Maturing Fistula Cases (Power Point)
      

   3. Role of competing vessels (In progress – Check back soon)
      

      1. Embolization vs. ligation

   4. Protocols, importance of limiting repeats, getting catheters out once mature, etc (In progress – Check back soon)

   5. Evidence basis
      
      References: Immature Fistula

   6. Surgical options (In progress – Check back soon)

4. Screening for fistula failure –
   
   Screening (video)
   
   K/DOQI Vascular Access Guideline 5
   
   VAMP© Vascular Access Monitoring and Surveillance Flow Chart
   

5. Angioplasty of failing fistulae –
   
   PTA (Video)
   

   1. Basic techniques (In progress – Check back soon)

   2. Pharmacologic adjuncts (eg heparin, NTG) (In progress – Check back soon)

   3. Endpoint determination (In progress – Check back soon)

   4. Common complications and management (In progress – Check back soon)

   5. Special Situations
      
      Cephalic Arch Stenosis (Power Point)
      
      Recommended Followup of Cephalic arch Lesions (Power Point)

   6. Role of stents and covered stents
      
      Stents (Video)

   7. Role of other adjuncts-cryo, cutting balloon, etc (In progress – Check back soon)

   8. Post procedure management and follow-up (In progress – Check back soon)

   9. Evidence Basis (In progress – Check back soon)

   10. Surgical options (In progress – Check back soon)
       

6. Thrombolysis and thrombectomy of clotted fistulae –

   1. Patient selection-time from event, size of fistula, comorbidities, etc (In progress – Check back soon)

   2. Techniques (In progress – Check back soon)
      

      1. Pharmacomechanical

      2. Mechanical
         
         Declotting (Video)
         
         Endovascular Recanalization of Thrombosed AVF’s (Video)
         
         Endovascular Recanalization of Thrombosed AVF’s (Handout)
         

   3. Endpoint determination (In progress – Check back soon)

   4. Tips and Tricks

      1. Hemostasis-
         
         Purse String Suture (Power Point w/Video)
         
         Woggle Technique (Power Point w/Video)
         

   5. Common complications and management (In progress – Check back soon)

   6. Post procedure management and follow-up (In progress – Check back soon)

   7. Evidence basis
      
      References: Fistula Declot

   8. Surgical options (In progress – Check back soon)

7. Steal

   1. Evaluation of steal
      
      Management of Steal Syndrome(Video)
      
      Management of Steal Syndrome (Handout)
      

   2. Interventions for steal (In progress – Check back soon)

   3. Evidence basis (In progress – Check back soon)

   4. Surgical options
      
      Management of Steal Syndrome(Video)
      
      Management of Steal Syndrome (Handout)
      

8. Aneurysms/pseudoaneurysms
   
   K/DOQI Vascular Access Guideline 5
   

   1. Surgical options (In progress – Check back soon)

9. Catheters
   

   1. Hazards of catheters
      
      Change Concept 7 AVF Placement in Patients with Catheters Where Indicated

   2. Tunneled vs. Nontunneled (In progress – Check back soon)

   3. Appropriate vessel choice (In progress – Check back soon)

   4. Device choice (In progress – Check back soon)

   5. Patient education at time of insertion (In progress – Check back soon)

   6. Prompt removal when no longer needed (In progress – Check back soon)
      
      Track ALL Catheter Patients for Early Removal of Catheters
      
      Management of Patients with Central Venous Catheters Algorithm

   7. Management of complications (In progress – Check back soon)

      1. Infection

      2. Flow problems

      3. Venous thrombosis

   8. Evidence basis (In progress – Check back soon)

10. Ways of developing interdisciplinary collaboration “Process”-  (In progress – Check back soon)