E2856. The Fistula Fix: Maturation, Maintenance, and De-Clots
  1. Anne Sailer; Yale School of Medicine
  2. Irene Dixe de Oliveira Santo; Yale School of Medicine
  3. Margarita Revzin; Yale School of Medicine
  4. Shin Mei Chan; Yale School of Medicine
  5. Nadia Solomon; Yale School of Medicine
  6. Juan Carlos Perez Lozada; Yale School of Medicine
  7. Angelo Marnio; Yale School of Medicine
Long-term dialysis access is essential in patients with end stage renal disease, with arteriovenous fistulae are the best form of hemodialysis access, followed by a graft, followed by a tunneled dialysis catheter. Extensive effort must be put forth to preserve and maintain these valuable access sites, particularly the arteriovenous fistulas and grafts. The typical fistula or graft is created from the distal radial artery to an adjacent forearm vein. Surveillance and proper maintenance of fistulas and grafts must be performed to ensure maturation, and maintain dialysis access through surveillance imaging, particularly when the patient has high pressures during or bleeding after dialysis. When permanent dialysis access thrombose, a rapid declot is necessary to maintain fistula and graft patency. This exhibit reviews approaches to de-clotting and maintaining fistulae, focused on common areas of stenosis and advanced declotting techniques to maintain long-term dialysis access. Common procedural complications and their treatment or follow-up are also reviewed.

Educational Goals / Teaching Points
Discuss epidemiology, cases, and clinical presentations of hemodialysis (HD) access failure requiring intervention and literature-based treatment interventions. Review role of imaging in the diagnosis of hemodialysis access malfunction/failure. Briefly review characteristic area of stenosis/failure based on HD access anatomy. Review main interventional therapies for management of HD access with emphasis on angioplasty, stent placement, and de-clot interventions.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Ultrasound and conventional angiogram evaluation and function and HD access maturity (rules of sixes), including common artifacts and pitfalls and advanced ultrasound techniques. Overview of the anatomy and physiology of characteristic HD areas of stenosis. Overview of the current literature of HD access failure treatment: drug-coated versus non-drug-coated balloons, covered versus bare-metal stents. Case-based review of various endovascular techniques in management of fistula malfunction including failure to mature, outflow stenosis treatment (characteristic HD access areas of stenosis such as the swing-point in BVT fistulas, cephalic arch stenosis, etc.), de-clot (traditional versus IJ access), coil embolization of accessory veins to aid in maturation, anastomotic narrowing, and intraprocedural complications.

Understanding fistula anatomy, common areas of stenosis/failure, and techniques to perform a successful de-clot is preserve long-term dialysis access. This exhibit provides an extensive overview to help interventionalists develop tips and tricks to assist with primary and secondary fistula and graft patency.