BackTable / VI / Podcast / Episode #77
Endovascular AV Fistula Creation
with Dr. Neghae Mawla
Interventional Nephrologist Neghae Mawla from Dallas Nephrology Associates walks us through his experiences with endovascular AV Fistula creation, including devices, patient prep, procedure steps and post procedure care.
BackTable, LLC (Producer). (2020, August 17). Ep. 77 – Endovascular AV Fistula Creation [Audio podcast]. Retrieved from https://www.backtable.com
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Dr. Neghae Mawla
Dr. Neghae Mawla is an Interventional Nephrologist with Dallas Nephrology Associates in Texas.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
In this episode, Dr. Neghae Mawla joins Dr. Chris Beck to discuss endovascular AV fistula creation. The episode begins by discussing the advantages of fistulas versus catheters and grafts and how guidelines have changed from “Fistula First” to the most appropriate type of access for the patient. Dr. Mawla explains the details of how he determines candidates for the EndoAVF using ultrasound for vein mapping.
We then review patient preparation for EndoAVF including anticoagulation, antibiotics, and anesthesia. We share the two main systems for EndoAVF, Avenu Ellipsys and the WavelinQ device and discuss the similarities and differences between these two approaches for fistula creation. Dr. Mawla walks through his ultrasound-guided techniques and the need for dual venous and arterial access with the WavelinQ device. They review some potential complications with using these devices, including hematomas and uncontrolled arterial bleeds, and post-procedural management. Dr. Mawla discusses timelines for evaluating venous maturation in patients and when a fistula is typically ready for use. He explains the differences between EndoAVF and surgically created fistulas, including several advantages of endo-anastomosis.
The episode ends by talking about EndoAVF education in dialysis centers and collaborating with nursing staff, clinics, and both device companies to re-educate staff and patients on differences in cannulation.
Hull JE, Jennings WC, Cooper RI, Waheed U, Schaefer ME, Narayan R. The Pivotal Multicenter Trial of Ultrasound-Guided Percutaneous Arteriovenous Fistula Creation for Hemodialysis Access.J Vasc Interv Radiol. 2018;29(2):149-158.e5. doi:10.1016/j.jvir.2017.10.015. https://avenumedical.com/wp-content/uploads/2018/03/avenu-us-pivotal-trial-jvir-feb-2018.pdf
Lok CE, Rajan DK, Clement J, et al. Endovascular Proximal Forearm Arteriovenous Fistula for Hemodialysis Access: Results of the Prospective, Multicenter Novel Endovascular Access Trial (NEAT).Am J Kidney Dis. 2017;70(4):486-497. doi:10.1053/j.ajkd.2017.03.026. https://www.ajkd.org/article/S0272-6386(17)30692-3/fulltext
It's all about outcomes in terms of infection rates and quality. The quality of dialysis with a catheter is always lower, and the only reason catheters are still around is because of immediate use. Even then immediate use graft still takes two or three days to let the soft tissue swelling to calm down before you can access it. The graft is immediate use, but the tissue may not allow immediate use, and a lot of times that's okay, but the infection rates for catheters are higher. The outcomes with catheters at the dialysis level, and those patients are clearly lower, so that's why we made a big push to avoid catheters. The outcomes for fistulas are better than grafts in terms of lifespan, and infection, so that's why this initiative came out with Fistula First, to really try to get a fistula in someone who's a candidate because that's where the better outcomes were.
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