Presented by Dr. Ari Kramer at the 47th Annual AAKP National Patient Meeting
Summary written by Michelle Brigham, RN, Clinical Specialist for Vasc-Alert, LLC
Dr. Kramer begins his presentation with a quote by Katherine Russell - “Every problem has a solution; it may sometimes just need another perspective.” He relates this to the chronic kidney disease and AV access community in an effort to help the audience understand that although there are and have been previous solutions we must continue to explore and expand further. He continues by presenting astounding statistical information about the large number of people who have or are at risk for chronic kidney disease and those who have a need for dialysis treatments. With the large and ever-growing population of people who require dialysis as treatment for end stage renal disease Dr. Kramer stresses that there is also a continued need for innovations in vascular access care. Hemodialysis is the most common type of dialysis treatment performed and can only be done if the patient has a functioning vascular access. There are three main options for vascular access available – the arteriovenous fistula (AVF), the arteriovenous graft (AVG), and the central venous catheter (CVC) – listed in order of preference.
PERCUTATIOUS FISTULA CREATION
The first innovation in vascular access care Dr. Kramer discusses is the percutaneous AVF stating that AV fistulas themselves are considered the first choice of access because of their many benefits and the fact that they generally “provide the healthiest means to receive dialysis”. Historically, creating an AVF required a surgeon for placement, but because time on a surgeon’s schedule and time in a surgical environment must be secured these procedures are often delayed. More recently there have been two options for AVF placement that have become more widely available and used to create accesses for dialysis patients. These two options allow AVF’s be placed in office settings and can be performed by physicians other than surgeons thus reducing the need for surgical time. They also don’t require large incisions and so reduce the time for recovery and healing for the patient.
The first option for creating a percutaneous AVF is the Ellipsys Vascular Access System provided by Medtronic. This device offers a single point of venous access that makes AVF creation more easily accessible. The second option is the WavelinQ, developed by BD, which also allows an AVF to be created in an outpatient setting. Dr. Kramer explains that the innovation and development of these two devices has provided solutions such as expanding the pool of who is available to create and have a role in the maturity of the AV access and allow for timelier and more consistent placement. Dr. Kramer reports that because Ellipsys and WavelinQ allow more patients to have an AV access efficiently placed, it has also subsequently reduced the number of patients who receive hemodialysis treatment via a central venous catheter, the least preferred vascular access due to high risks of central venous stenosis, infection, and many other complications.
INNOVATIVE AV GRAFTS
The next innovation Dr. Kramer touches on is related to the AV graft, a prosthetic material used to bridge an artery and a distal vein allowing cannulation for hemodialysis treatment. Patients who are not considered candidates for an AVF will often have an AVG placed since the AVG has fewer complications than the central venous catheter. Dr. Kramer discusses the InnAVasc Arteriovenous Graft that was designed to reduce the risk of complications and bleeding due to the need for repeated cannulations for treatment. InnAVasc has an easily identifiable ‘safe stick zone’ which allows reproducible, consistent cannulations. This in turn reduces the risk of infiltrations and unsuccessful cannulations which can lead to loss of confidence from patients. Because InnAVasc improves the ability for successful cannulation, it also provides more opportunity for patients to receive hemodialysis in a home setting.
DRUG COATED ANGIOPLASTY BALLOONS
These advancements to AV access creation and use have proven extremely beneficial to dialysis patients, but that does not replace the need for ongoing surveillance and maintenance to ensure that adequate blood flow is achieved and that the patient is able to receive successful dialysis treatments. Like creation and maintenance, devices for treatment of AV access complications have also seen improvements. Until recently plain balloon angioplasties were used to access and treat areas of stenosis. Dr. Kramer presents information related to recent research that supports the use of drug coated balloons with a molecule called Paclitaxel to be a more successful method. Medtronic was involved with a study for their InPact Admiral in which the results showed that greater than 80% of AV accesses were able to achieve primary patency through six months. In summary, the advancements and the use of drug coated balloons has provided better solutions for patients with recurring complications, less reliance on artificial implants such as stents, and reduction in likelihood of AV access clotting.
DEVICES TO IMPROVE FISTULA MATURATION
To continue the discussion about failure in AV accesses, specifically AVF’s, Dr. Kramer presents information about the recent development of VasQ. VasQ is a device that was designed to reduce stenoses in newly created AVF’s from the natural turbulent flow that happens when the vein and the artery are surgically connected. It has allowed improved fistula maturation and reduces occurrences of juxta-anastomotic stenosis in turn leading to improved AVF usability.
HOME HEMODIALYSIS MACHINES
There have also been advancements in the world of home hemodialysis. One of the unfortunate circumstances that sometimes prevents a patient from being able to do hemodialysis at home is that it requires space and adequate water supply. Fortunately, the development of the Quanta home dialysis machine has allowed this option for more patients. The Quanta is smaller in size, can hook up standard home water supply, and uses disposable cartridges which makes use easier for patients and their caregivers and also reduces infection risks. Equally important, the Quanta also allows dialysis providers access to remote monitoring of the patient’s treatment details.
REMOTE PATIENT MONITORING
The final innovation Dr. Kramer discusses, Alio’s Smart Patch, is a device that will allow monitoring of a patient’s AV access remotely rather than only when in the dialysis clinic. The Smart Patch will also have other key dialysis metrics available when it is commercially released in the US. Federal mandates require many elements of a dialysis patient’s treatment and care be routinely monitored, one of these being the AV access. Alio’s Smart Patch is an external device (similar to a band aid) applied just over the access that provides remote data to caregivers for clinical metrics such as potassium levels, hemoglogin, hematocrit, blood pressure, and blood flow. Improvements in monitoring these indicators allows for more proactive care for dialysis patients.
In summary, Dr. Kramer’s presentation provided us with information related to many innovations and improvements that will be coming soon to the renal community. Whether you are a patient, caregiver, or dialysis provider it is important that you continue to explore the best options available.