P1314TEN YEAR EXPERIENCE ON VASCULAR ASSESS PLACEMENT BY NEPHROLOGIST
Authors: Mahapatra Himansu , Pursnani Lalit , B Muthukumar , Inamdar Neeraj , Kumar Adarsh , DP Kushal , Binoy Renju , Kaur Navjot , Singh Mansi , Kumari Anamika , Krishnan Chandra 
Published: June 2020

Abstract

Background and Aims
Across the globe, vascular assess placement for haemodialysis is performed by Anaesthesiologist, Nephrologist, Radiologist, and surgeons depending on the experts availability of that locality. Patient care should not suffer because of lack of round the clock surgical and radiological expertise. We would like to share our ten year experience of vascular assess placement and their outcomes which were performed in the Department of Nephrology.

Method
A total 11429 vascular assess procedures have been carried out during 2009 to 2019. There were 781 AVF, cuffed 476 and non-cuffed 10172 (Internal Juglar 5375, Subclavian 2042 and femoral 2755) catheter insertions were performed. For construction of AVF, Pre-procedure ultrasound Doppler was performed to see both the anatomy of vein and artery. Radiocephalic and brachiocephalic AVF construction were done by side to side arteriovenous anastomosis using 6-0 Prolene double ended needle under strict asepsis. Insertion complications (bleeding and air-embolism), procedure time, patency, blood flow, and post-procedure complications (hematoma) were recorded. Follow up was done on 10th and 30th day of post surgical period. Of 476 Permcath, 58 were placed without valve guided peel away sheath catheters and rest with valve guided peel away sheath catheters in right internal jugular vein.

Results
Of 781 AVF, 557 (71.3%) were males and mean age 42.7±15.1 years. Of them, diabetes 330 (42.25%) and non-diabetes 451 (57.74%) were, Basic disease were DM 134 (16.15%), HTN 115 (14.72%), CGN 121 (15.49%), CTIN 124 (15.87%), Unknown 173 (22.15%) and others 114 (14.59%) were respectively. Common sites of AVF site were were left radiocephalic 319 (40.84%), left brachiocephalic 321 (41.1%) and both side brachiobasilic 141 (18%). Pre procedure ultrasound doppler findings were arterial diameter 2.79±0.96, venous diameter 2.75±0.86, arterial pulse wave velocity 57.93±19.49, diameter. The average duration of the procedure was 70 min without any intra operative complication. Five patients developed post-operative bleeding required re-exploration. The average duration between the construction of the fistula and the day of successful cannulation was 37 days. After six weeks venous diameter were 5.06±1.58 having blood blow of 766.17±536.36 ml/min. Successful cannulation could be done in 418 (53.52%) patients and another 363 (46.47%) patients did not have satisfactory thrill even after the stipulated time of maturation were declared failed AV fistulas. Other common complications observed were stenosis 351 (44.94%), edema 140 (17.92%), ischemia 124 (15.87%), thrombosis 124 (15.87%), infections 109 (13.95%) and aneursyms 112 (14.34%) respectively
The technical success rate of catheter placement were 98% without any major insertion or post-procedure complications. Average procedural time was 20 minutes. Mal position of Permcath was seen in 38 (7.9%) patients, catheter thrombosis 45 (9.4 %) patients.

Conclusion
It is quite safe for nephrologists to perform surgical procedures required for vascular access for dialysis. The valve-guided tunnelled catheter insertion and side to side anastomosis AVF construction may be adopted as a routine practice by the Nephrologists.