8. Symposium DialyseshuntchirurgieFortbildungsveranstaltung der IAD, Hotel Elephant, Weimar 11.12.2015
D. Döbrich, Th. Röder, Y. Al-Shargabi
Determinanten der Shuntoffenheit
HELIOS Klinik Blankenhain
HELIOS Klinik BlankenhainDeterminanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 2
HELIOS Klinik Blankenhain
Einflussfaktoren der Shuntoffenheit
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015
AlterGeschlechtBody Mass IndexHerzinsuffizienzAntikoagulanzienAndere Medikamente (z. B. Ca++-Kanal Blocker, Statine)
Vaskuläre Risikofaktoren
Arterielle Hypertonie
Hyperlipidämie
Diabetes mellitus
Nikotinabusus
3
Winkelmayer, Wolfgang C., "Tackling the Achilles' Heel of Hemodialysis," New England Journal of Medicine, 2011, 372 - 374.Smith, George E., Gohil, Risha und Chetter, Ian C., "Factors affecting the patency of arteriovenous fistulas for dialysis access," Journal of Vascular Surgery, 2012, 849 - 855.Puskar, Damir, Pasini, Josip, Savic, Ivan, Bedalov, Goran und Sonicki, Zdenko, "Survival of primary arteriovenous fistula in 463 patients on chronic hemodialysis," Croatian medical journal, 2002, 306-11.Monroy-Cuadros M, Yilmaz S, Salazar-Bañuelos A, Doig C. Risk Factors Associated with Patency Loss of Hemodialysis Vascular Access within 6 Months. Clinical Journal of the American Society of Nephrology : CJASN. 2009; 5:1787 - 1792
HELIOS Klinik Blankenhain
Einflussfaktoren der Shuntoffenheit
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015
Gefäßparameter
Durchmesser
Arterial Resistance Index
Venous Distensibility
Shuntart
Operateur / OP-Technik
Anastomosenart
Präoperativer Ultraschall
Postoperative Flussmessung
4
Winkelmayer, Wolfgang C., "Tackling the Achilles' Heel of Hemodialysis," New England Journal of Medicine, 2011, 372 - 374.Smith, George E., Gohil, Risha und Chetter, Ian C., "Factors affecting the patency of arteriovenous fistulas for dialysis access," Journal of Vascular Surgery, 2012, 849 - 855.Puskar, Damir, Pasini, Josip, Savic, Ivan, Bedalov, Goran und Sonicki, Zdenko, "Survival of primary arteriovenous fistula in 463 patients on chronic hemodialysis," Croatian medicaljournal, 2002, 306-11.Monroy-Cuadros M, Yilmaz S, Salazar-Bañuelos A, Doig C. Risk Factors Associated with Patency Loss of Hemodialysis Vascular Access within 6 Months. Clinical Journal of the American Society of Nephrology : CJASN. 2009; 5:1787 - 1792
HELIOS Klinik Blankenhain
Eigene Patienten
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015
Erstanlagen
Radiocephale Shunts
Terminale Niereninsuffizienz
n = 133
Primäre Shuntoffenheit
„Zeitintervall von der Shuntanlage bis zu jeder ersten Intervention/Operation um die Shuntfunktion zu erhalten oder zu verbessern“
5
Sidawy AN, Gray Richard Besarab A, Henry Mitchell Ascher E et al. Recommended standards for reports dealing with arteriovenous hemodialysis accesses. Journal ofVascular Surgery. 2002; 35:603 - 610.
HELIOS Klinik Blankenhain
Demographische Daten
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 6
Geschlechtsverteilung Altersverteilungn = 133
HELIOS Klinik Blankenhain
Body Mass Index
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 7
https://en.wikipedia.org/wiki/Body_mass_index#/media/File:Body_mass_index_chart.svg
HELIOS Klinik Blankenhain
Comorbiditäten
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 8
56% 56% 96% 30%
HELIOS Klinik Blankenhain
Comorbiditäten
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 9
Herzinsuffizienz Diabetes mellitus
HELIOS Klinik Blankenhain
Alter
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 10
EinflussShuntreifung Shuntoffenheit Quelle
Ø Olsha, Oded, Hijazi, Jamal, Goldin, Ilya und Shemesh, David, "Vascular access in hemodialysis patients older than 80 years," Journal of Vascular Surgery, 2015, 177 - 183.
Ø Lauvao, Lannery S., Ihnat, Daniel M., Goshima, Kaoru R. et al., "Vein diameter is the majorpredictor of fistula maturation," Journal of Vascular Surgery, 2009, 1499 - 1504.
Ø Swindlehurst, Nicola, Swindlehurst, Andrew, Lumgair, Heather et al., "Vascular access forhemodialysis in the elderly," Journal of Vascular Surgery, 2011, 1039 – 1043
+Tordoir, J. H. M., Bode, A. S. und van Loon, M. M., "Preferred Strategy for HemodialysisAccess Creation in Elderly Patients," European Journal of Vascular and EndovascularSurgery, 2015, 738 - 743.
+Monroy-Cuadros M, Yilmaz S, Salazar-Bañuelos A, Doig C. Risk Factors Associated with Patency Loss of Hemodialysis Vascular Access within 6 Months. Clinical Journal of the American Society of Nephrology : CJASN. 2009; 5:1787 - 1792.
ØAllon, Michael, Litovsky, Silvio, Young, Carlton J. et al., "Medial fibrosis, vascularcalcification, intimal hyperplasia, and arteriovenous fistula maturation," American journal ofkidney diseases : the official journal of the National Kidney Foundation, 2011, 437-43
HELIOS Klinik Blankenhain
Alter
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 11
LogRank-Test (5%)
HELIOS Klinik Blankenhain
Geschlecht
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 12
EinflussShuntreifung Shuntoffenheit Quelle
Ø Lauvao, Lannery S., Ihnat, Daniel M., Goshima, Kaoru R. et al., "Vein diameter is themajor predictor of fistula maturation," Journal of Vascular Surgery, 2009, 1499 - 1504.
+Bashar, Khalid, Zafar, Adeel, Elsheikh, Sawsan et al., "Predictive parameters ofarteriovenous fistula functional maturation in a population of patients with end-stage renal disease," PloS one, 2015, e0119958.
HELIOS Klinik Blankenhain
Geschlecht
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 13
keine Herzinsuffizienz (nw= 37, nm= 56)
LogRank-Test (10%)
HELIOS Klinik Blankenhain
Diabetes mellitus Typ II
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 14
EinflussShuntreifung Shuntoffenheit Quelle
Ø Lauvao, Lannery S., Ihnat, Daniel M., Goshima, Kaoru R. et al., "Vein diameter is themajor predictor of fistula maturation," Journal of Vascular Surgery, 2009, 1499 - 1504.
+Conte, Michael S., Nugent, Helen M., Gaccione, Peter, Roy-Chaudhury, Prabir und Lawson, Jeffrey H., "Influence of diabetes and perivascular allogeneic endothelial cellimplants on arteriovenous fistula remodeling," Journal of vascular surgery, 2011, 1383-9.
ØSedlacek, M., Teodorescu, V., Falk, A., Vassalotti, J. A. und Uribarri, J., "Hemodialysisaccess placement with preoperative noninvasive vascular mapping: comparison betweenpatients with and without diabetes," American journal of kidney diseases : the officialjournal of the National Kidney Foundation, 2001, 560-4.
ØAllon, Michael, Litovsky, Silvio, Young, Carlton J. et al., "Medial fibrosis, vascularcalcification, intimal hyperplasia, and arteriovenous fistula maturation," American journalof kidney diseases : the official journal of the National Kidney Foundation, 2011, 437-43.
+Monroy-Cuadros M, Yilmaz S, Salazar-Bañuelos A, Doig C. Risk Factors Associated with Patency Loss of Hemodialysis Vascular Access within 6 Months. Clinical Journal of the American Society of Nephrology : CJASN. 2009; 5:1787 - 1792.
HELIOS Klinik Blankenhain
Diabetes mellitus Typ II
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 15
LogRank-Test (9%)
HELIOS Klinik Blankenhain
Body Mass Index
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 16
EinflussShuntreifung Shuntoffenheit Quelle
+Evans, Richard P. T., Meecham, Lewis, Buxton, Pauline et al., "Vascular access in theobese: superficialisation of native radio-cephalic and brachio-cephalic fistulae," The journal of vascular access, 2015, 126-9.
+Kim, Jwa-Kyung, Jeong, Jae Han, Song, Young Rim et al., "Obesity-related decrease in intraoperative blood flow is associated with maturation failure of radiocephalicarteriovenous fistula," Journal of vascular surgery, 2015, 1010-1017.e1.
Ø Lauvao, Lannery S., Ihnat, Daniel M., Goshima, Kaoru R. et al., "Vein diameter is themajor predictor of fistula maturation," Journal of Vascular Surgery, 2009, 1499 - 1504.
HELIOS Klinik Blankenhain
Body Mass Index
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 17
LogRank-Test (41%)
HELIOS Klinik Blankenhain
Hyperlipidämie
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 18
EinflussShuntreifung Shuntoffenheit Quelle
+De Marchi, S., Falleti, E., Giacomello, R. et al., "Risk factors for vascular disease andarteriovenous fistula dysfunction in hemodialysis patients," Journal of the American Society of Nephrology : JASN, 1996, 1169-77.
Ø Lauvao, Lannery S., Ihnat, Daniel M., Goshima, Kaoru R. et al., "Vein diameter is themajor predictor of fistula maturation," Journal of Vascular Surgery, 2009, 1499 - 1504.
HELIOS Klinik Blankenhain
Hyperlipidämie
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 19
LogRank-Test (78%)
HELIOS Klinik Blankenhain
Arterielle Hypertonie
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015
Die Variabilität des systolischen Blutdrucks korreliert signifikant mit dem Risiko einer Shuntdysfunktion. Mutmaßlich erhöht der hohe systolische Blutdruck die Entzündungsaktivität in der Venenwand.Cheng, Yue, Zhang, Fan, Zhu, Jun et al., "Influence of blood pressure variability on the life of arteriovenous fistulae in maintenance hemodialysispatients," Clinical hemorheology and microcirculation, 2015,.
20
HELIOS Klinik Blankenhain
Herzinsuffizienz
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015
Die Wahrscheinlichkeit, die Dialyse mit einem suffizienten Shunt zu beginnen ist bei Patienten mit Herzinsuffizienz 34% niedriger.Lilly, Michael P., Lynch, Janet R., Wish, Jay B. et al., "Prevalence of arteriovenous fistulas in incident hemodialysis patients: correlation with patient factors that may be associated with maturation failure," American journal of kidney diseases : the official journal of the National Kidney Foundation, 2012, 541-9.
21
HELIOS Klinik Blankenhain
Herzinsuffizienz
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 22
LogRank-Test (20%)
HELIOS Klinik Blankenhain
Durchmesser Arterie
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015
Der Mindestdurchmesser der A. radialis für eine optimale Shuntreifung und lange primäre Offenheit ist 2 mm.Kordzadeh, Ali, Chung, Jameson und Panayiotopoulos, Yiannis P., "Cephalic vein and radial artery diameter in formation of radiocephalic arteriovenousfistula: a systematic review," The journal of vascular access, 2015, 506-11.
23
HELIOS Klinik Blankenhain
Durchmesser Arterie
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 24
LogRank-Test (28%)
HELIOS Klinik Blankenhain
Keine Herzinsuffizienz
Herzinsuffizienz und arterieller Gefäßdurchmesser
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 25
LogRank-Test (87%)
HELIOS Klinik Blankenhain
NYHA III-IV
Herzinsuffizienz und arterieller Gefäßdurchmesser
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 26
LogRank-Test (1%)
HELIOS Klinik Blankenhain
Durchmesser Vene
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 27
EinflussShuntreifung Shuntoffenheit Quelle
+Kordzadeh, Ali, Chung, Jameson und Panayiotopoulos, Yiannis P., "Cephalic vein andradial artery diameter in formation of radiocephalic arteriovenous fistula: a systematicreview," The journal of vascular access, 2015, 506-11.
+ Lauvao, Lannery S., Ihnat, Daniel M., Goshima, Kaoru R. et al., "Vein diameter is themajor predictor of fistula maturation," Journal of Vascular Surgery, 2009, 1499 - 1504.
+ +Dageforde, Leigh Anne, Harms, Kelly A., Feurer, Irene D. und Shaffer, David, "Increasedminimum vein diameter on preoperative mapping with duplex ultrasound is associatedwith arteriovenous fistula maturation and secondary patency," Journal of VascularSurgery, 2015, 170 - 176.
HELIOS Klinik Blankenhain
Durchmesser Vene
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 28
LogRank-Test (13%)
HELIOS Klinik Blankenhain
Keine Herzinsuffizienz
Herzinsuffizienz und venöser Gefäßdurchmesser
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 29
LogRank-Test (59%)
HELIOS Klinik Blankenhain
Herzinsuffizienz NYHA III / IV
Herzinsuffizienz und venöser Gefäßdurchmesser
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 30
LogRank-Test (6%)
HELIOS Klinik Blankenhain
Thrombozytenaggregationshemmer
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 31
EinflussShuntreifung Shuntoffenheit Quelle
Ø +Jackson, Andrew J., Coats, Paul und Kingsmore, David B., "Pharmacotherapy to improveoutcomes in vascular access surgery: a review of current treatment strategies," Nephrology Dialysis Transplantation, 2012, 2005 - 2016.
Ø +Dember, Laura M., Beck, Gerald J., Allon, Michael et al., "Effect of clopidogrel on earlyfailure of arteriovenous fistulas for hemodialysis: a randomized controlled trial," JAMA, 2008, 2164-71.
Ø +Palmer, Suetonia C., Di Micco, Lucia, Razavian, Mona et al., "Antiplatelet Therapy toPrevent Hemodialysis Vascular Access Failure: Systematic Review and Meta-analysis," American Journal of Kidney Diseases, 2013, 112 - 122.
HELIOS Klinik Blankenhain
Keine Herzinsuffizienz
Thrombozytenaggregationshemmer
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 32
LogRank-Test (59%)
HELIOS Klinik Blankenhain
Herzinsuffizienz NYHA III-IV
Thrombozytenaggregationshemmer
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015 33
LogRank-Test (20%)
HELIOS Klinik Blankenhain
Fazit
Determinanten der Shuntoffenheit | D. Döbrich, Th. Röder, Y. Al-Shargabi | Weimar | 11.12.2015
• Bei Patienten mit einer relevanten Herzinsuffizienz keine Shuntanlagen mit grenzwertig kleinen Gefäßen
• Die bestmögliche Behandlung der kardiovasculär relevanten Begleiterkrankungen dient auch der Shuntoffenheit.
34
Vielen Dank!Dr. med. Dinah DöbrichHELIOS Klinik Blankenhainwww.helios-kliniken.de
Für Fragen und Hinweise stehe ich in der Diskussion sowie danach gerne zur Verfügung, auch via