AV Access Surgery Products >   Guide to Vessel Sizes and Flow Ranges Flow-Based Vascular Access Management Handbook

Best Practice:

Use Transonic intrao-perative flow measurements to ensure successful revision of high-flow fistulas to correct steal syndrome and cardiac stress.

Flow-based Access Revision Surgery           

High flow in an over-maturing fistula leads to cardiac overload and hand ischemia, commonly corrected by a banding procedure. Without direct flow measurement, the procedure may yield anything from no flow change to low flow fistula failure. Intraoperative flow measurements, using either Transonic’s surgical or minimally invasive OptiMax® flowprobes, provide the surgeon with quantitative flow data to guide the procedure.¹

Flow-directed Fistula Banding

Two conditions mandate the need to increase venous flow resistance through a high flow AV fistula used for hemodialysis. They include:

• Clinical significant Hemodialysis Access-induced Distal Ischemia (HAIDI), a potentially devastating AV access complication that occurs primarily in diabetic ESRD patients. Banding relieves distal ischemia (Steal) by increasing fistula resistance.
• Cardiac Overload when fistula flow is so high that it places too much stress on the heart and endangers heart function. Banding increases fistula resistance, lowers fistula flow and reduces stress on the heart.

Dr. M.R. Scheltinga from Maxima Medical Center, Veldhoven, The Netherlands has pioneered use of the new OptiMax Banding Flowprobe to direct banding of fistulas. By measuring venous outflow intraoperatively as the fistula is banded, the quantitative flow measurements guide the surgeon as the band is tightened to achieve a target post-operative flow goal.

AV Fistula DRIL Procedure for Distal Ischemia (Steal) Syndrome (ISS)

Distal revascularization-interval ligation (DRIL) technique is an alternative way to manage ISS. The procedure:

• eliminates the potential pathway for steal syndrome by ligating the artery distal to the origin of the AV fistula
• revascularizes the extremity through creation of a bypass (saphenous vein, PTFE graft) from above the AV fistula to below AV fistula.

Case Studies:

• ISS: Management by Radial Artery Bypass Graft
• Cephalic Arch Stenosis

Recommended Flowprobes

References

1. Van Hoek F et al, “Banding of Hemodialysis Access to Treat Hand Ischemia or Cardiac Overload,” Sem in Dialysis 2009; 22(2):204-208.