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BackTable / VI / Podcast / Episode #292

Dialysis Interventions with Drug-Coated Balloons, Covered Stents and More

with Dr. Ari Kramer

In this episode, Dr. Chris Beck interviews vascular access surgeon Dr. Ari Kramer about his management of arteriovenous (AV) access for dialysis patients. We cover his preferred imaging for identifying and deciding to treat stenoses, the protracted angioplasty technique, and the evolution of research in drug coated balloons (DCB) and stent grafts.

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Dialysis Interventions with Drug-Coated Balloons, Covered Stents and More with Dr. Ari Kramer on the BackTable VI Podcast)
Ep 292 Dialysis Interventions with Drug-Coated Balloons, Covered Stents and More with Dr. Ari Kramer
00:00 / 01:04

BackTable, LLC (Producer). (2023, February 17). Ep. 292 – Dialysis Interventions with Drug-Coated Balloons, Covered Stents and More [Audio podcast]. Retrieved from https://www.backtable.com

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Podcast Contributors

Dr. Ari Kramer discusses Dialysis Interventions with Drug-Coated Balloons, Covered Stents and More on the BackTable 292 Podcast

Dr. Ari Kramer

Dr. Ari Kramer is the Chairman of the Department of Surgery at Spartanburg Regional Healthcare System in Spartanburg, South Carolina.

Dr. Christopher Beck discusses Dialysis Interventions with Drug-Coated Balloons, Covered Stents and More on the BackTable 292 Podcast

Dr. Christopher Beck

Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.

Synopsis

Dr. Kramer starts by describing his vascular access practice. He is the sole operator within a hospital-based practice where he creates and maintains AV access. When evaluating a patient for possible intervention, duplex ultrasound, physical exam findings, patient history, and information from the dialysis center all play roles in determining whether the patient is eligible for a fistulagram. Dr. Kramer offers fistulagram tips: he obtains access above the arterial anastomosis in order to avoid occlusion of outflow, and he first shoots contrast into the venous tract first and works his way up to the arterial system. Depending on the findings of the fistulagram, stenotic lesions in the venous outflow tract can be treated. Dr. Kramer generally treats the lesion if the stenosis limits flow by more than 50%. Additionally, he treats any lesion resulting in a luminal diameter of 2mm or less.

In an AV fistula circuit, Dr. Kramer describes his procedure, which is largely informed by the most current clinical trials. He first employs the FLEX Vessel Prep system to reduce circumferential fibromuscular tension. Next, he performs protracted plain old balloon angioplasty (POBA) for 90 seconds. This helps Then, he re-images the vessel to ensure there was no injury and utilizes a DCB to deliver paclitaxel. We discuss the clinical trials outcomes of the two current DCBs that have been approved for use in AV management, IN.PACT and Lutonix. Dr. Kramer also notes the significant cost of DCBs and lack of access to treatment for the most at-risk patients. He encourages clinicians to unite to advocate for increased reimbursement for this treatment that has been proven to show the highest standard of care.

Additionally, we address treatment of non-autogenous AV circuits with stent grafts. Dr. Kramer prefers self-expanding covered stents, such as Viabahn or Covera, since they are conformable and resistant to kinks. Overall, Dr. Kramer emphasizes the importance of the operator staying up to date on clinical trials that show data for diverse tools with various indications, knowing their own skill and comfort, and incorporating the best treatments based on their patient and practice context.

Resources

Ep. 139 AV Fistula Graft Management:
https://www.backtable.com/shows/vi/podcasts/139/av-fistula-graft-maintenance

FLEX Vessel Prep System:
https://www.venturemedgroup.com/

KDOQI Clinical Practice Guideline for Vascular Access, 2019 Update:
https://www.ajkd.org/article/S0272-6386(19)31137-0/fulltext

Fahrtash, F., Kairaitis, L., Gruenewald, S., Spicer, T., Sidrak, H., Fletcher, J., Allen, R., & Swinnen, J. (2011). Defining a significant stenosis in an autologous radio-cephalic arteriovenous fistula for hemodialysis. Seminars in dialysis, 24(2), 231–238.
https://doi.org/10.1111/j.1525-139X.2011.00861.x

Haskal, Z. J., et al. (2010). "Stent graft versus balloon angioplasty for failing dialysis-access grafts." New England Journal of Medicine 362(6): 494-503.

Haskal, Z. J., et al. (2016). "Prospective, Randomized, Concurrently-Controlled Study of a Stent Graft versus Balloon Angioplasty for Treatment of Arteriovenous Access Graft Stenosis: 2-Year Results of the RENOVA Study." Journal of Vascular and Interventional Radiology 27(8): 1105-1114 e1103.

Vesely, T., et al. (2016). "Balloon angioplasty versus Viabahn stent graft for treatment of failing or thrombosed prosthetic hemodialysis grafts." Journal of Vascular Surgery.

Falk A, Maya ID, Yevzlin AS; RESCUE investigators. A prospective, randomized study of an expanded polytetrafluoroethylene stent graft versus balloon angioplasty for in-stent restenosis in arteriovenous grafts and fistulae: two-year results of the RESCUE study. J Vasc Interv Radiol. 2016;27:1465-1476.

Bard Peripheral Vascular. Covera vascular covered stent instructions for use. Rev.4 / 08-18.
http://www.bardpv.com/eifu/uploads/BAWB05872R4-Covera-Vascular-Covered-Stent-IFU.pdf.

Trerotola, S. O., et al. (2018). "Drug Coated Balloon Angioplasty in Failing AV Fistulas: A Randomized Controlled Trial." Clinical Journal of the American Society of Nephrology 13(8): 1215-1224.

Trerotola, S. O., et al. (2019). "The Lutonix AV Randomized Trial of Paclitaxel-Coated Balloons in Arteriovenous Fistula Stenosis: 2-Year Results and Subgroup Analysis." Journal of Vascular and Interventional Radiology.

The Fight Doctors:
https://thefightdoctors.com/about/

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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