Angioplasty procedure for AV-

shunt stenosis
Atma Gunawan
Nephrology and Hypertension Division
Saeful Anwar Hospital Malang
 Fistula Maturation
• Definition: Process by which a fistula becomes suitable
for cannulation (ie, develops adequate flow, wall
thickness, and diameter)
• Rule of 6’s: In general, a mature fistula should:
– Be a minimum of 6 mm in diameter with discernible
margins when a tourniquet is in place
- Lenghth > 6 cm
– Be less than 6 mm deep
– Have a blood flow greater than 600 mL/min
– Be evaluated for nonmaturation 6-8 weeks after
surgical creation, ideally after 12 weeks

National Kidney Foundation. Am J Kidney Dis. 2006;48(suppl 1):S1-S322.

 AVF failure
• Primary failure due to poor maturation of
AVF~ 60% failure rate -NIH sponsored DAC
study, JAMA 2008
• Primary patency rate at 1 year : 62.5%
• A risk prediction for fistulae failure : age ≥ 65
years, peripheral vascular disease, coronary
artery disease, female, diabetes
 Treatment Flow at Nagoya Kyoritsu Hospital
AVF： arteriovenous fistula AVG：arteriovenous graft
-Abnormality (by inspection, palpation, -Abnormality (by inspection, palpation,
auscultation), longer hemostasis auscultation), longer hemostasis
-Blood flow malfunction -Increase in venous pressure (by over 50
mmHg from previous PTA)
Once More than
No significant once
stenosis Vascular
ultrasound No significant
stenosis

Significant
stenosis

Angiography
Need observation Need observation

3 months or more from previous PTA：PTA

Less than 3 months from previous PTA：Revascularization
NKH Vascular Access Treatment Center
AVF ultrasound
Common site of stenosis in av-fistulae

Turmel-Rodrigues L, et al. Nephrol Dial Transplant 2000;15:2032-2036,

 Indications for intervention
on AV-fistulae
• Inadequate flow to support the prescribed
dialysis blood flow. (B). Indonesian : Qb <200
ml/min (?)
• Hemodynamically significant venous stenosis. (B)
• Aneurysm formation in a primary fistula.
Postaneurysmal stenosis that drives aneurysm
also should be corrected. The aneurysmal
segment should not be cannulated. (B)
• Ischemia in the access arm (B).
CLINICAL PRACTICE GUIDELINES FOR VASCULAR ACCESS (KDOQI 2006)
 Indications for preemptive PTA
• A fistula with a greater than 50% stenosis in
either the venous outflow or arterial inflow, in
conjunction with clinical or physiological
abnormalities, should be treated with PTA or
surgical revision. (B)
• Abnormalities include reduction in flow,
increase in static pressures, access
recirculation preempting adequate delivery of
dialysis, or abnormal physical findings. (B)

CLINICAL PRACTICE GUIDELINES FOR VASCULAR ACCESS (KDOQI 2006)

Stenosis : >50%
 Bahan dan Alat
Bahan dan alat :
• Introducer sheat 6Frx11cm • Diameter balloon : 1 sd 2 mm diatas
• Guidewire hydrophilic 0,035"x150- diameter normal vein
200 cm , tip : angle and straight • ∅ balloon v. Cephalica dan basilica
• Vert Diagnostic catheter 5Frx100-150 (AVF baru : 6 mm, AVF lama sd 9 mm)
cm (support/guiding catheter) • ∅ balloon untuk central vein stenosis
• Balloon angioplasty catheter (sistem 10-14 mm
0,035 ", ukuran ∅ 5-6 mm, panjang 4-
6 cm, panjang catheter 75-100 cm) .
Pressure 10 sd 20 atm.
• Inflator device
• Abbocath/IV canula no 18 G
• Mess no11
• Spuit Injection 10 cc 2
• Lidocain ampul 2%
• Heparin 5000iu/5mL
 Introducer sheath
• Intravascular sheath—should always
be used.
• The size of the sheath is determined
by the diameter of the angioplasty
balloon that is to be used.
• Catheter and sheath : French/F (1
French = 0.33 mm)
• Sheath size : inner diameter ;
Catheter size : outer diameter. 5F
catheter fits into 5F sheath
• In general 6-F shealth is appropriate
for standarad catheter with balloon
in the 8 –mm diameter.
• Some interventionalists prefer a-7F
sheath to encountered when
removing the balloon after inflation
Sheath length 10 cm
Plastic Straight and Angled (J)
0.025" (0.64 mm) for 4 Fr, straight
Mini guidewire mini guidewire type; 0.035" (0.89
mm) for all others
45 cm
Plastic IV Catheter - 18G x 2 ½" (1.2 x
64 mm),except for 4 Fr with 45 cm
Entry needle straight mini guidewire: 20G x 2" (0.9
x 51 mm)
2.5 ml syringe is included
0.025" (0.64 mm) for 4 Fr, straight
Guidewire compatibility mini guidewire type
0.035" (0.89 mm) for all others
Packaging Tray
​Sheath, dilator, plastic mini guidewire
​A Kit content
and plastic IV catheter (entry needle)
 Guidewires
• Guidewires are used to introduce, position, and exchange catheters
• In a standard guide wire, a stainless steel coil surrounds a tapered inner
core
• The guidewire should be twice the length of the longest catheter being
used
• Core material : nitinol (fexible,durable, risk fracture), steel (support,
push,kink, less flexible)
• Coating : hydrophillic (attracts water, becomes gel when wet,needs
lubrication to perform,reduces friction, increases trackability ),
hydrophobic (repels water,silicone on working area of wire, excluding
tip,no wetting required,reduces friction,increases trackability)
Wire selection

• Diameter Guidewire : in thousandths of an inch (1 inch=2.54 cm).

• Diameter vary from 0.014 in to 0.038 in.

• Most commonly used size is 0.018“/0.035“ ( upper extremity) and 0.014“/

0.018“ ( lower extremity)

• Length between 130 and 300cm

• Tip configurations are; straight, angled Tip and J shape

• Varying degrees of shaft stiffness ( e.g. extra support, super stiff wires) allow
advancement of stiff devices
 Guidewires for AVF
• The standard diameter is
0.035 in.
• 0.018 in. wires are also
frequently used especially
in AVF interventions.
• Non-hydrophilic vs.
hydrophilic wires (low
friction).
• Lengths from 145 cm to
260 cm.
 Route of guidewire

Where the location of the stenosis is known, one may choose

an approach leading directly to the stenosis
 GUIDING/SUPPORT CATHETERS
• Guiding catheters: to add support to the wire
to cross the difficult lesions and to inject
contrast for angiography.
• Why so many sizes & shapes? No two
anatomies are the same
Guiding catheter and guidewire
 Balloon Dilatation Catheter
Components
Length

Diameter
1. 2. Tip
Balloon

4. Distal 3.
5. Catheter
Shaft Markers
Platform
6. Coating

Illustrations are artist’s rendition and are not drawn to scale.

Mustang™ Balloon Dilatation
Catheter

Catalog Diam (mm) Leng (mm) Shaft (cm) Sheath (F) RBP (atm)
3917106044 6 40 40 5 24
3917106047 6 40 75 5 24
3917106041 6 40 135 5 24
3917106064 6 60 40 5 24
3917106067 6 60 75 5 24
 Balloon catheter
• In selecting a balloon, the following criteria should be
considered: Guidewire ( 0.014“, 0.018“, 0.035“), over the wire
(OTW) or monorail system (rapid exchange), shaft length
• The manufacturer specifies the required sheath size in the
label of the balloon catheter.
• 0.014“ balloon system is usually for carotid, vertebral, renal,
infrapopliteal arteries
• 0.018“ balloon system also in SFA (superficial femoral artery),
infrapopliteal, depends on what the operator prefers
• 0.035“ balloon system for subclavian, innominate, aortoiliac,
superficial femoral artery, AVF
 Balloon catheter
• For (non-coronary) percutaneous transluminal angioplasty
(PTA), balloon sizes typically range from 4 to 12 mm in
diameter and 20 to 100 mm in length. Rated pressures for
PTA 8-20 ATM
• Usually, balloons with 4 to 8 mm diameter and 20 to 60 mm
length are used for most AVF and AVG interventions.
• The balloon should be 20-30% larger than the normal
vessel diameter judged by comparison with the vessel
lumen adjacent to the lesion.
• Shorter lengths often lead to slipping of the balloon off the
stenosis; while longer lengths often cause unnecessary
endothelial damage at the normal vessel.
• For central vein lesions, 12-16 mm balloons are needed
Balloon catheter
Inflator : barrel, plunger,
manometer (30-atm maximum pressure)
 Medications
• Prophylactic antibiotics—NOT necessary for routine
vascular access intervention with standard aseptic
technique
• For patient restless : midazolam 2.5 to 5 mg iv slowly.
Pateint age >70 years : diazepam 2 to 10 mg iv slowly
• Analgesia : metamizol 1 gr iv
• If the patients are already on antiplatelet agent such as
aspirin or clopidogrel, it should be continued as the risk
of excessive bleeding from antiplatelet agents from
percutaneous intervention is minimal.
• Many interventionists may initiate antiplatelet therapy
if stent or stent-graft is placed.
 Medications
• PTT 2 to 2.5 times normal value (70 to 90
seconds)
• At the beginning : patient given
unfractionated heparin 3000 to 5000 iu
• In longer intervention : 1000 iu heparin per
hour

Book : Peripheral vascular intervention. Schroder Jurgen.2012)

 Procedure of
angioplasty

1. Venography
2. Angioplasty
 Angiography Suite

Portable
ultrasound
unit

fluoroscopy
 Venography
• Jarum uk 18 G dimasukan ke
venous limb ke arah lesi stenosis
• Pasang manset di proksimal dari
tempat insersi, pompa pada
tekanan diatas diastolik dan
pertahankan.
• 20-30 cc kontras (isoosmolar non
ionic: visipaque,iopamidol)
diinjeksikan secara cepat dengan
kecepatan 4 cc/detik
• Gambar fistulogram diambil
dengan metode fluoroscopy atau
DSA (digital substraction
angiography)

Ny. Sayati,54 th. 16 Maret 2019

Angioplasty
Percutaneous
puncture
Masukan mini guidewire
sheath melalui IV canule.
Anestesi dengan lidocain.
Canule dilepas
Incisi entry site 2 mm
dengan mess
Masukan introducer
sheath. Dilator dan guide
wire dilepas
• Prosedur dengan tuntunan fluoroscopy
• Guide wire 0.035 dimasukan melalui
sheath, dilakukan manipulasi sehingga
ujung guide wire melampaui lesi stenosis.
• Apabila ujung guide wire kesulitan
melampaui area stenosis, maka dibantu
dengan support catheter.
• Heparin 3000 iu dimasukan melalui side
port introducer sheath
Angioplasty
• Kateter balon
dimasukan melalui
guidewire, didorong
sehingga melewati dan
berada di area stenosis
• Dengan menggunakan
inflator , balon diinflate
dengan pressure mulai
10,15,20 atm sampai residu
stenosis tidak terlihat.
Setiap inflate dipertahankan
1 menit, dan diulang 2 atau
3 kali
 Angioplasty
• Balon di deflate, ditarik
keluar. Guide wire
dipertahankan.
• Kontras diinjeksi melalui
support catheter untuk
melihat lesi
• Guide wire ditarik,
sheath dilepas, entry
site dijahit dan ditekan.
Evaluasi USG doppler
pasca angioplasty
Wassalam
Video angioplasty AV-F stenosis