ASDIN 10th Annual Scientific Meeting Final
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
Presenter Disclosure Information
Inside-Out Central Venous Access
John C. Gurley, MD
University of Kentucky
John C Gurley, MD
Renal Denervation: The Case for Cardiology
FINANCIAL DISCLOSURE:
Investigator: Medtronic (SYMPLICITY HTN), St. Jude Medical (EnligHTN)
Grants: None related to this topic
Speakers Bureau: Cryolife
Development Interests: Therix Medical, Bluegrass Vascular Technologies
UNLABELED/UNAPPROVED USES DISCLOSURE:
This presentation may describe hardware that has been modified and/or utilized in a
manner that is not consistent with labeled instructions for use.
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
We are our own worst enemy
American Society of Diagnostic
& Interventional Nephrology
Wall Structure: Artery versus Vein
Comparison of artery and vein
American Society of Diagnostic
& Interventional Nephrology
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Arterial versus Venous Occlusion: Fundamental Difference
Normal Artery
Adaptive Remodeling
Normal Vein
Acute Thrombosis
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Diseased artery (atherosclerosis)
American Society of Diagnostic
& Interventional Nephrology
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When they’re gone… they’re gone
Chronic Occlusion
Chronic Occlusion:
Fibrous Cord
1
ASDIN 10th Annual Scientific Meeting Final
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
PHOENIX 2014
American Society of Diagnostic
& Interventional Nephrology
Approach to Complex Central Venous Occlusions
How to get into the right atrium
___________________________
Complex recanalization
____________
Balloons
_________
Stents
Transhepatic Access
______________________
Translumbar Access
_______________________
Direct Atrial Access
___________________________
Femoral and Iliac Access
_______________________
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
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American Society of Diagnostic
& Interventional Nephrology
How to get out of the right atrium.
American Society of Diagnostic
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PHOENIX 2014
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American Society of Diagnostic
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Anatomical basis for Inside-out access
Type 1. IJ and/or SC occlusion
Type 2. Brachiocephalic w/ patent SVC
C
SC
AZ
SVC
RAA
Type 3. SVC above azygos
Type 4. SVC below azygos
IVC
2
ASDIN 10th Annual Scientific Meeting Final
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
Identify the SVC stump (RAO 30 o)
Azygos (posterior)
SVC (anterior)
Blunt dissection
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
Fabricate a needle from .018” steel wire
Skin marker
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
3
ASDIN 10th Annual Scientific Meeting Final
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
American Society of Diagnostic
& Interventional Nephrology
American Society of Diagnostic
& Interventional Nephrology
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
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ASDIN 10th Annual Scientific Meeting Final
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
Blunt dissection to head of clavicle followed by insideout puncture (supraclavicular exit)
RAO 30
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Conventional device implant (CRT-D)
American Society of Diagnostic
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Device Types
Ports
4%
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
IOCVA for cardiopulmonary bypass circuits
Example of 31 F Avalon ECMO cannula despite
occluded central veins
Others1
10%
CIEDs
11%
Temp HD
12%
Other tunneled
Chronic HD access
58%
4%
1. Includes temporary infusion catheters, heart and liver biopsies, ECMO, and structural heart interventions
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ASDIN 10th Annual Scientific Meeting Final
PHOENIX 2014
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
American Society of Diagnostic
& Interventional Nephrology
Combining inside-out access with HeRO graft
IOCVA fluoro time (minutes)
Mean 3.5 ±4.1, Median 2.1 minutes
Venous collaterals are
adequate if not arterialized
100
Count
80
60
40
20
Diverting graft flow directly
to RA provides effective relief
from severe extremity edema
0
2.6%
16.4%
20
to
30
30
to
40
40
to
50
50
to
60
60
to
70
American Society of Diagnostic
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70
to
80
80
to
90
90
to
100
More
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Repeat procedures
Type of central venous occlusion
None1
10
to
20
PHOENIX 2014
American Society of Diagnostic
& Interventional Nephrology
Type 4
SVC at RA
0
to
10
Four or more1
IJ/SC
11.2%
Three procedures
8%
9%
Two procedures
Brachiocephalic
17%
29.3%
Type 3
SVC above azygos
One procedure
67%
40.5%
1. Unable to obtain conventional access due to trauma, immobilization, and/or other local factors
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
Time for a new paradigm
Save the veins
• Begin with a long-term vein use strategy
– Prevent occlusions rather than treat
•
•
•
•
Commit to preserving central veins
Recycle occluded veins, don’t sacrifice good ones
Insist on upper-body access
Never use leg veins for chronic access
Improvised hardware utilized in an offlabel manner not very appealing.
6
ASDIN 10th Annual Scientific Meeting Final
American Society of Diagnostic
& Interventional Nephrology
American Society of Diagnostic
& Interventional Nephrology
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
PHOENIX 2014
PHOENIX 2014
American Society of Diagnostic
& Interventional Nephrology
American Society of Diagnostic
& Interventional Nephrology
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
PHOENIX 2014
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ASDIN 10th Annual Scientific Meeting Final
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
Thank you!
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
First-in-Human Data
•
•
Presented at ISET 2013
12 patients treated
– Severe renal dysfunction
– Upper extremity venous occlusive disease
requiring hemodialysis
•
•
100% technical success
0% adverse events
•
100% patency of venous access
– At 48hrs and 14-days
– At 14-day follow-up
“The learning curve is just one. In the beginning, you
think that it will be very complex and after, you realize
that it is very easy.”
- A. Ebner, Principal Investigator
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
8
ASDIN 10th Annual Scientific Meeting Final
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
Sometimes the scariest things come from within.
Approach to Complex Central Venous Occlusions
How to get into the right atrium
Complex recanalization
Balloons
Stents
Transhepatic Access
Translumbar Access
Direct Atrial Access
Femoral and Iliac Access
9
ASDIN 10th Annual Scientific Meeting Final
American Society of Diagnostic
& Interventional Nephrology
PHOENIX 2014
10