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Protesi artero-venose:
indicazioni e materiali.
Massimo Morosetti
Direttore UOC Nefrologia e Dialisi
Direttore DEA
Ospedale GB Grassi Roma
FAV protesiche prossimali
FAV protesiche arto inferiore.
La protesi ideale
Emocompatibile
Biocompatibile Duratura
Maneggevole
Elastica
Flessibile
Buona compliance
Resistente alle infezioni
Resistente alle punture
No seroma
No trombogenesi
?
Carboflo
Carboflo
Risultati
Venaflo II
Venaflo II
Flusso nell’anastomosi venosa
Risultati
AVflo© Vascular Access Graft
Multistrato
A novel electrospun nano-fabric graft allows early cannulation
access and reduces exposure to central venous catheters.
Karatepe C, Aitinay L, Yetim TD, Dagli C, Dursun S
Results: Successful access was achieved in all 24 patients within 48 hours.
In 50% of the patients cannulation was performed within 24 hours without
increasing the complication rate. Twelve month primary and secondary
patencies were 50% and 70.8%, respectively. Excluding early failures
(within 30 days) because of surgical problems, 12 month primary and
secondary patencies were 75% and 81.2% respectively. Complication and
infection rates were 10.94 and 0.49/1000 dialysis procedures, respectively.
No pseudoaneurysms or seromas were documented at 18 months.
Conclusions: Early cannulation was successful in all patients with good 12-
month primary and secondary patency rates, compared to data reported by
others on polytetrafluoroethylene (PTFE) grafts. The infection rate was
substantially lower than in tunneled CVCs. Therefore, the AVflo graft may
improve the clinical status of dialysis patients by decreasing the exposure
to CVCs.
J Vasc Access. 2013
HeRO Graft
HeRO Graft (Hemodialysis
Reliable OutFlow) is the ONLY
fully subcutaneous AV access
solution clinically proven to
maintain long-term access for
hemodialysis patients with central
venous stenosis.
ePTFE Graft
Beading (3-4cm) for kink resistance .
Orientation line on graft to guide
placement during tunneling. Titanium
connector
Silicone-Coated Reinforced Nitinol
No venous anastomosis
Reinforced 48 braid nitinol: kink &
crush resistant
Removable and replaceable
Radiopaque band (at distal tip)
HeRO Graft
HeRO Graft
HeRO Graft
Outcomes comparison of HeRO and lower extremity arteriovenous
grafts in patients with long-standing renal failure. Steerman SN, Wagner J, Higgins JA, Kim C, Mirza A, Pavela J, Panneton JM, Glickman MH
60 HeROs were placed in 59 patients and 22 LEAVGs were placed in 21 patients.
Mean follow-up was 13.9 months for the HeRO group and 11.9 months for the LEAVG group.
The HeRO patients underwent a mean of 6.3 previous tunneled dialysis catheter insertions and
3.1 previous AVG/arteriovenous fistula placements.
The LEAVG patients underwent placement of a mean of 4.1 previous tunneled dialysis catheters
and 2.6 previous AVG/arteriovenous fistulas.
The principal difference was the number of interventions to maintain patency, which was 2.21 per
year in the HeRO group and 1.17 per year in the AVG group (P = .003)
Secondary patency at 6 months was 77% for the HeRO patients and 83% for the LEAVG patients
(P = .14). The HeRO and LEAVG groups had no difference in infection rate per 1000 days (0.61
vs 0.71; P = .77) or mortality rate (22% vs 19% respectively; P = .22) at 6 months.
CONCLUSIONS:
In access challenged patients, LEAVG and HeRO offer similar rates of secondary patency,
infection, and all-cause mortality. The LEAVG required fewer interventions to maintain patency,
and the HeRO maintains the benefit of utilizing the upper extremity site of venous drainage. In our
practice, we prefer the HeRO to LEAVG, especially in patients with peripheral arterial disease and
in the obese population, because it preserves lower extremity access options.
J Vasc Surg. 2013 Mar;57(3):776-83;
Percutaneous interventions on the hemodialysis reliable outflow
vascular access device. Gebhard TA, Bryant JA, Adam Grezaffi J, Pabon-Ramos WM, Gage SM, Miller MJ,
Husum KW, Suhocki PV, Sopko DR, Lawson JH, Smith TP, Kim CY.
RESULTS:
The mean time from HeRO implantation to initial dysfunction or thrombosis was 171
days. In 60 (82%) procedures, the HeRO device was thrombosed. An intragraft
stenosis was the most common lesion identified (59%; n = 43) followed by an arterial
anastomosis stenosis identified in 18% (n = 13). In 22% (n = 16) of procedures in
which the HeRO device was thrombosed, an underlying cause was not identified after
thrombectomy. The 3-, 6-, and 12-month primary patency rates after intervention
were 47%, 37%, and 26% for first-time interventions. The secondary patency rates
were 80%, 70%, and 64%. The only complication was pulmonary embolism resulting
in death 2 days after HeRO thrombectomy.
CONCLUSIONS:
Percutaneous interventions on thrombosed and failing HeRO devices yielded
acceptable primary and secondary patency rates after intervention in these patients
with few, if any, alternatives for hemodialysis access.
J Vasc Interv Radiol. 2013 Apr;24(4):543-9.
La protesi biosintetica
Tubo di collagene ovino maturo sviluppato
attorno ad un modello di poliestere a rete
La rete in poliestere, parte integrante della
parete della protesi, è circondata ed
incapsulata dal collagene
Il collagene è sterilizzato con glutaraldeide
Retta e loop
Collagene
Poliestere Glutaraldeide
Biocompatibilità
Emocompatibilità
Durata
Elasticità
Non antigenico
Duraturo
La protesi biosintetica associa la biocompatibilità
delle protesi biologiche alla durata delle
sintetiche senza valvole e diramazioni
Accurato lavaggio
Anastomosi venosa e tunnel
Anastomosi arteriosa e finale
Sopravvivenza protesi
54
37
30
0
10
20
30
40
50
60
Basale Primaria 6 mesi Primaria 12 mesi
47 Osservati
7 Deceduti 45 Osservati
2 Deceduti
78.7%
66.6%
J Vasc Surg. 2011 Jul 29.
Conclusions of the study
From these results we believe that BBAVF
should be the first choice in patients with a good
life expectancy (2 years) and who can rely on an
available temporary VA, such as a central
venous catheter. However, given the shorter
time to use, AVG could be an alternative choice
in patients with compromised clinical conditions
and in whom a temporary VA is not reliable,
considering that the long-term outcome may be
considered beneficial regardless.
Morosetti M et al: J Vasc Surg. 2011 Jul 29.
A systematic review of cohort studies to
evaluate the associations between type of
vascular access (arteriovenous fistula,
arteriovenous graft, and central venous
catheter) and risk for death, infection, and
major cardiovascular events
Associations between hemodialysis access type and
clinical outcomes: a systematic review. Ravani P, Palmer SC, Oliver MJ, Quinn RR, MacRae JM, Tai DJ, Pannu NI, Thomas C, Hemmelgarn
BR, Craig JC, Manns B, Tonelli M, Strippoli GF, James MT.
In conclusion, persons using catheters for
hemodialysis seem to have the highest risks for
death, infections, and cardiovascular events
compared with other vascular access types, and
patients with usable fistulas have the lowest risk.
J Am Soc Nephrol. 2013 Feb;24(3):465-73
Effect of timing of the first cannulation on survival of
arteriovenous hemodialysis grafts. Feldman L, Shani M, Mursi J, Beberashvili I, Bass A, Weissgarten J, Rabin I
According to the time, in weeks, between graft construction and its
first successful cannulation, the grafts were divided into six groups:
2nd, 3rd, 4th, 5th, 6th and 7th or more week after surgery.
In the whole cohort, the incidence of primary graft failure at 12
months was 72.2%, and the incidence of cumulative graft failure at
12 months was 40.7%.
The incidences of primary graft failure and cumulative graft failure at
12 months did not differ significantly between the study groups.
In our study, timing of the first cannulation of a new arteriovenous
polytetrafluoroethylene graft had no significant impact on graft
survival.
Ther Apher Dial. 2013 Feb;17(1):60-4.
Conclusions: In our experience, the intensive
follow-up controls did not improve the
permeability of the Hax-AVF, although re-
operations due to obstruction did diminish.
The follow-up of these access fistulas should
be clinical based on hemodialysis data,
leaving ultrasonographic evaluation for
those cases where a malfunction is
suspected.
Grazie per l’attenzione !
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