1 of 73

2 of 73

Dialysis Access

History and Perspectives
Peritoneal Dialysis and Associated Surgical Care
Embedded PD Catheter - Why and How
Hemodialysis Access

David S Bjerken MD FACS

DaVita Physician Support Network

Medical Director, McLeod Loris Dialysis Access Center

Myrtle Beach, SC

3 of 73

Disclosures

I am a consultant for DaVita, Vantive, Merit Medical and Medtronic.

Not selling anything in those roles! Teaching techniques to proceduralists.

I am an avid NHL fan and want the Minnesota Wild to win the Stanley Cup.

4 of 73

Brief History of Dialysis, Transplant and Dialysis Access��

1924 first dialysis in human 15 min Germany
1937 Dialyzer with cellophane membranes(now Polysulfone)
1949 glass shunt(ligate vessels)
1954 first renal transplant(1936 failed, no immunosuppression)
1960 (Quinton)Scribner shunt(PTFE cannulas)
1961 Catheters(FA/FV FV/FV)
1965 Brescia Cimino first AV fistula
1972 PL 92-603 Medicare Entitlement for ESRD (no more selection committees “God Committees”)
1972 AV graft bovine carotid artery(now Artegraft)
1976 PTFE graft
1995 NKF KDOQI Kidney Disease Quality Outcomes Initiative CPG
2004 Fistula First Initiative
Innovation in the dialysis access space continues to flourish.

5 of 73

ESRD Prevalence Trends (United States)

Data based on United States Renal Data System (USRDS) annual reports.

Year	Total Prevalent ESRD Cases (Approximate)	Primary Drivers/Notes
1990	~180,000	Early growth of dialysis infrastructure.
2000	~370,000	Expansion of Medicare coverage for ESRD.
2010	~590,000	Increased obesity and diabetes rates.
2015	~700,000	Improvements in cardiovascular care (patients living longer).
2020	~800,000+ 71% dialysis, 29% transplant	Significant growth in home dialysis and transplant waitlists.

6 of 73

Aging Out

in the

US

7 of 73

1. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update Lok, Charmaine E. et al. American Journal of Kidney Diseases, Volume 75, Issue 4, S1 - S164�

National Kidney Foundation KDOQI CPG for Vascular Access 2019

We have a clinical imperative to ensure “the right access for the right patient at the right time for the right reasons,”¹

8 of 73

Shifting Mantra��Shifting ‘PLAN’

“Fistula First” Initiative 2004

“Fistula First, Catheter Last”

“The Right Access in the Right Patient at the Right Time for the Right Reasons” 2019

ESKD “Life PLAN”

PLAN = Patient LifePlan Access Needs

Contingency and Succession Plans for Access

9 of 73

Forms of dialysis and access

Transplant

PD

Fistula

Graft

Catheter

10 of 73

METRICS!�Our Nephrologists are held to many Metrics…

Learn the challenges of your nephrologists to better align your service to their needs…

In-Center catheter rates – monthly
CVC days – 90 day deadline
Fistula percentage in-center
“Home Penetration” PD + HHD 25% per 2019 executive order
“Optimal Start “- without a central venous catheter(CVC)
Missed treatment days

11 of 73

What’s the story with PD?

Historically underutilized.
Training in nephrology and surgical programs is insufficient.
Catheter dysfunction 10-15%
Products and supply needs are poorly understood.
“Everything is urgent”.

These are challenges:

PD has HUGE clinical benefits for the patient.
Best Demonstrated Practices are defined.
Metrics are driving change.
Teamwork is strong with GS, VS, IR, IN, DaVita, Vantive, Merit, Mozarc .

Reasons for optimism:

12 of 73

What are the advantages of Peritoneal Dialysis (PD)?

Preserves residual renal function ¹

Early survivor advantage ²

Decreased hospitalization rates ³

Prevents need for central venous catheters

Gets patients Medicare sooner⁴

Higher quality of life measures ⁵

Lower overall cost of care

Better outcomes at transplantation

¹ He, L et al. Perit Dial Int. 2016 May-Jun; 36(3):334–339. ² Source: 2016 USRDS Annual Data Report, Volume 2 – ESRD in the United States; Chapter 5 – Mortality; Sinnakirouchenan, R and Holley, JL. Adv Chronic Kidney Dis. 2011 Nov; 18(6):428–432. ³ US Renal Data System, 2016 Annual Data Report. ⁴ Homedialysis.org, Medicare Calculator. ⁵ Helanterä, I et al. Am J Kidney Dis. 2012; 59(5):700–706
Add’l Resources:
Arshia Ghaffari and Jorge Doria Medina Sanchez. Peritoneal Dialysis Should Be Considered the First Option for Patients Requiring Urgent Start Dialysis: PRO. Kidney 360. April 12, 2022.
François K, Bargman JM. Evaluating the benefits of home-based peritoneal dialysis. Int J Nephrol Renovasc Dis. 2014 Dec 4;7:447-55. doi: 10.2147/IJNRD.S50527. PMID: 25506238; PMCID: PMC4260684.

12

13 of 73

Methods

Matched

Retrospective

1:1 Cohort Study

No prior

Kidney Smart Education

Home

Dialysis

Permanent

Vascular Access

Received

Prior Kidney Smart Education

38.5%

1. Reference: Utilization of Home Dialysis and Permanent Vascular Access at Dialysis Initiation Following a Structured CKD Education Program; Katherine Mckeon, Scott Sibbel, Steven M. Brunelli, Erin Matheson, Nick Lefeber, Meghan Epps, and Francesca Tentori

Utilization of Home Dialysis and Permanent Vascular Access at Dialysis Initiation Following Kidney Smart CKD Education Program

One-time

In-person/Virtual Kidney Smart class

Cohort

Results

Primary Outcomes

Secondary Outcomes

57.9%

1.00

Hospitalization

Admissions/

patient year

1.38

33.8%

12.6%

Mortality

Higher mortality in first year

Lower mortality

p < 0.001

Conclusion: Attending a Kidney Smart CKD Education class prior to starting dialysis was associated with positive clinical outcomes, including lower hospitalization and mortality rates.

2,398 Adults with CKD

14 of 73

Embedded Catheters Can Reduce the Gap Between Those that Chose PD and Those that Start PD �

~48%

Chose PD

and started dialysis

Chose

PD and started PD

The Gap

Unplanned start on HD with CVC

Angiographic procedures
Acute illness, e.g. infection, MI
Acute decline in kidney function
Patient indecision and missed appointments
OR or surgeon unavailability for late PD access procedure

Percent

Pyart et al. Perit Dial Int 2018; 38:328-333

Liebman et al. Am J Kidney Dis 2012; 59: 550–557

Heaf et al. Clin Kidney J 2021; 14:2064-2074

Heaf et al. Clin Kidney J 2021; 14:933-942

14

15 of 73

Majority of Patients “Crash” in to Dialysis

And CVC becomes the default access option¹

60%

of patients who progress to ESRD do not have a distinct plan at the time of dialysis therapy initiation³

80%

of patients were using a CVC at HD initiation²

Sources: 1) Machowska A, Alscher MD, Vanga SR, Koch M, Aarup M, Ruthorford P. Offering Patients Therapy Options in Unplanned Start: Development and Implementation of an Education Program for Unplanned-Start Patients. Advances in Peritoneal Dialysis;31:69-73. | 2) US Renal Data System, 2022 Annual Data Report | 3) Ghaffari A. Urgent-start peritoneal dialysis: a quality improvement report. Am J Kidney Dis. 2012;59: 400–408

16 of 73

Change in Dialysis Access Type Over 18 Months Following Initiation of HD with a CVC�

USRDS 2020 ADR, Figure 3.8b

16

17 of 73

Understanding Basics of PDC Placements

3 Placement Techniques

3 Types of Proceduralists

3 Scenarios for Patient Timelines

Open Surgical
Laparoscopic
Percutaneous

Surgeons GS, VS
Interventional Radiologist (IR)
Interventional Nephrologists (IN)

Embedded
Routine
Urgent

17

18 of 73

Peritoneal Dialysis Catheter Placement Timeline�

Classification of Dialysis Start	Anticipated Dialysis Start Time
Urgent Start	24 hours to 14 days
Routine Start	14 days to 30 days
Embedded Catheter	2 to 12 months

How soon will the PD catheter be needed?

18

19 of 73

Examples of Patient Path to PD

HD Conversion

24 hours to 14 days

14 days to 30 days

> 90 days

30 days to 24 months or more

Allows for immediate initiation of full volume PD with minimal notice

Prevents patient from having weeks or months of an unused, exposed PD catheter

Enables a smooth transition to dialysis avoiding a crash start, CVC placement and associated complications

Embedded Catheter

Urgent Start

Planned but Crashed

No Prior Nephrologist Care

AKI staying on PD

Routine Start

Planned

Controlled

Start

Crash 🡪 HD 🡪 PD

Standard 🡪 HD 🡪 PD

20 of 73

Urgent Start PD – Use in less than 2 weeks from placement procedure��

Rectus Muscle and Sheath

Rectus Tunnel

Deep Cuff in Muscle

Purse String

Paramedian Incision

Avoid mid-line catheter insertion
Ensure deep cuff is within the rectus sheath
Rectus sheath tunneling of the catheter
Use purse-string suture

Urgent start PD:

Minimize intraperitoneal pressure with low-volume, strictly supine exchanges
Have dry periods to promote healing

Surgical

Clinical

Strategies to Prevent Early Pericatheter Leaks

20

21 of 73

Embedded Peritoneal Dialysis Catheters�Reasons to Use this Technique in General

Allows for growth of PD as an underutilized therapy
Elective procedure, allows time for pre-op clearance; better anesthetic risk compared to a semi urgent procedure^1,2
Patient is in better health at the time of the procedure (vs. sick/uremic)²
Externalization requires only local anesthetic, when they are symptomatic and higher anesthetic risk,.
Patient can start on FULL VOLUME PD, no break in period.
Cuffs are integrated, less exit site infection.

�

DaVita does not prescribe treatment type, frequency, or prescriptions, and defers to the nephrologist to prescribe on a patient by patient basis.

References: 1. Crabtree JH, Burchette RJ, Siddiqi RA. Embedded Catheters: Minimizing Excessive Embedment Time and Futile Placement while Maintaining Procedure Benefits. Perit Dial Int. 2015 Sep-Oct;35(5):545-51. doi: 10.3747/pdi.2013.00301. Epub 2014 Oct 7. PMID: 25292403; PMCID: PMC4597987.. 2. McCormick BB, Brown PA, Knoll G, Yelle JD, Page D, Biyani M, Lavoie S. Use of the embedded peritoneal dialysis catheter: experience and results from a North American Center. Kidney Int Suppl. 2006 Nov;(103):S38-43. doi: 10.1038/sj.ki.5001914. PMID: 17080110.

21

22 of 73

How to get great results and less catheter malfunction!�Best Demonstrated Practices

https://journals.sagepub.com/doi/pdf/10.3747/pdi.2018.00232

22

23 of 73

Challenges for Optimal Choice of Peritoneal Dialysis Catheters�

Odd Skin Folds

Obesity

Massive Weight Loss

Drooping Pannus

Adult Diaper

Intestinal Stoma

23

24 of 73

Must Have Flexibility in Exit-Site Placement�

A basic catheter inventory is mandatory to produce:

Presternal Exit-Site
Upper Abdominal Exit-Site
Mid-abdominal Exit-Site
Lower Abdominal Exit-Site

24

25 of 73

Standard Abdominal Catheters

25

Coiled-tip, 2-cuff, Straight Intercuff

Coiled-tip, 2-cuff, Intercuff Preformed Bend

Straight-tip, 2-cuff, Straight Intercuff

Straight-tip, 2-cuff, Intercuff Preformed Bend

USMP/MG2/16-0005a(2) 09/17

26 of 73

Extended Catheter System

Presternal or Upper Abdominal Catheter Exit Site

26

Titanium Connector

1 or 2-Cuff Extension Tube with Preformed Intercuff Bend

1-Cuff Coiled-Tip Catheter

27 of 73

Getting it Right! Use a Stencil to mark and choose Exit Site and Catheter

4 results of Stencil-based marking

Deep pelvic position of internal end
Position of paramedian incision and deep cuff is thereby determined
Ideal exit site is chosen
Catheter shape is determined

27

28 of 73

Conventional

Embedded

29 of 73

�Proactive and Adjunctive Procedures With Laparoscopic Implantation

Rectus sheath tunneling to promote pelvic orientation of catheter tip and prevent catheter tip migration.
2 Piece extended catheter systems – upper abdominal and presternal exit sites
Diagnosis and treatment of previously unsuspected hernias.
Selective prophylactic omentopexy (omental tacking procedure) to prevent catheter obstruction. 30%
Selective adhesiolysis to enable implantation and eliminate compartmentalization of peritoneal cavity. <31%
Resection of redundant epiploic appendices, epiploectomy, to prevent catheter obstruction.

29

30 of 73

Outpatient Peritoneal Dialysis for AKI

Starting in January 2025, CMS began authorizing reimbursement for home dialysis for AKI patients (including HHD and PD self-dialysis training)
AKI patients who choose PD may have a higher chance of renal recovery due to the therapy’s preservation of residual kidney function²
AKI patients typically treat with a CVC, increasing risks of infection, hospitalization and mortality making modality education and access planning prior to ESKD diagnosis are critical

1. American Nephrology Nurses Association. (n.d.). Acute kidney injury clinical fact sheet. https://www.annanurse.org/download/reference/practice/akiClinicalFactSheet.pdf

2. Rottembourg J. Residual renal function and recovery of renal function in patients treated by CAPD. Kidney Int Suppl. 1993 Feb;40:S106-10.

Acute Kidney Injury (AKI) is the sudden loss of kidney function within hours to days¹, requiring renal replacement therapy. Patients may partially or completely regain renal function, but others might never recover and may transition to ESKD.

30

31 of 73

Secondary Embedding: Option 2

Crabtree et al. Peritoneal dialysis catheter embedment: surgical considerations, expectations, and complications. Am J Surg 2013; 206:464-71.

This segment is removed.

Step 1 - Expose intercuff segment

Step 2 - Add extension with titanium connector

Step 3 - Tunnel to ultimate exit site

Step 4 – Embed and excise old exit site

Crabtree JH. Secondary embedding of peritoneal dialysis catheters. Perit Dial Int 2008; 28: 203–206.

31

32 of 73

Rescue from Catheter Malfunction�(You pretty much have to look = Laparoscopy, and we seldom need to remove or replace a catheter)�

Resolve constipation
TPA protocol
Laparoscopy
Fibrin
Omentum – omentopexy
Adhesions – SB, colon, colonic appendix epiploica, umbilical folds, fallopian fimbria,
Suture/tether/lasso the catheter to reposition

33 of 73

34 of 73

Redundant Omentum�

Omental Wrap

34

35 of 73

What to do with this??

Tunnel tract infection = Superficial cuff abscess

35

36 of 73

Hemodialysis Access�The Realities - The Challenges

Care is shared between multiple subspecialists GS,VS,IR,IN

Often none of these consider it a priority or a joy, rather an add-on to an otherwise complex practice.

Residency training is lacking.

Best practices are poorly defined.

Everything nephrologists want is urgent.

We are essentially continuously managing against failure.

37 of 73

Hemodialysis Access�The Bright Side(Maybe not sexy but can be attractive!)

The need is growing for access care.

It is a deeper speciality than one might expect, a challenging venture.

There are some good algorithms and standards.

Access care brings forth quite a lot of creativity.

The patients are underserved, appreciative, and offer long-term patient relationships.

There are worthwhile resources, VASA, CIDA.

It may seem altruistic(it is) but this is a very rewarding practice when taken as a whole.

38 of 73

~2x

risk for �hospitalizations

27

more days per year �in the hospital

7

additional hours �of RN time per �pt/per year

~4x

risk of �infection

Why Do We Care So Much About CVCs?

CVC Patients Have, On Average:

~2x

risk of mortality

39 of 73

Dialysis Basics �for the Non-Nephrologist

Dialysis Flow 450cc/min
Access Flow >600cc/min
BP and Cardiac Output concerns
Adequacy/Clearance/Kt/V(>1.2)

40 of 73

What Are the Elements of an Ideal Access?

Tailored to the individual patient’s needs

Meets the “Rule of 6’s”

Allows for prompt removal of a catheter

Matures within 60 days

40

41 of 73

Tailoring Access to the Patient

Not every patient needs a fistula

Patients with poor vasculature or short life expectancy may be better served with a graft

Early cannulation grafts may reduce or eliminate catheter days

There are alternatives for patients with “exhausted sites”

Plan ahead for “what’s next”

Logistical concerns may dictate access choice

41

42 of 73

Optimal Timeline —�Access referral to Cannulation(and Catheter out!)�

Day 0=Surgical referral

Day 10=Surgical Appointment + Mapping

Day 24=Surgical Access Creation

Day 66=First Cannulation – Mark Centerline

Day 80=Catheter out!

Maintenance 1.8x/year – triggers for evaluation

Post op appointments @3,6 weeks = Maturity

Our nephrologists and dialysis units are held to many metrics!

We need to help with catheter and fistula rates.

43 of 73

Cut to the Chase �Key Moves - Lessons learned over time

Ultrasound is your best friend. Vessel mapping preop, Choose a side R/L. Intraop confirm mapping, plan incision

Supraclavicular block – anesthetic safety and vasodilation.

Avoid side of pacer, AICD.

Avoid steal by RC or PRA anastomosis or axillary. Beware with PAD and go proximally.

Treat steal with PAI Proximalization of the Arterial Inflow 10+cm 4 mm artegraft

Office FU with US “Rule of 6’s” depth, diameter and BA flow, for assessment of maturity.

Early fistulagram if not maturing.

“It’s all about the tunneling” grafts, transposition and.catheters

44 of 73

Algorithm for maintenance and salvage

INFLOW

OUTFLOW

CONDUIT

45 of 73

Modes of �Access Care��“The Right Access for the Right Patient at the Right Time for the Right Reasons”

Create

Maintain

Salvage

Abandon

46 of 73

VESSEL MAPPING�

This worksheet is a basis for:
Choosing an arm
Predicting one or 2 choices
Relaying pertinent information(prior access, AICD, XRT, ALND)

47 of 73

Create Maintain Salvage Abandon��Inflow Outflow Conduit

Fistulas

Wrist - RC/Snuffbox

Upper arm - PRA/PUA/Gratz/BC/MC/BB

Transposition(lift, superficialization, elevation)

PSLOT anastomosis

Percutaneous Ellipsys WavelinQ

48 of 73

Always repeat ultrasound in OR after supraclavicular block

49 of 73

Access in Stage 4,5 – Not on Dialysis

“Fistula Only!!”

50 of 73

��

Rule of 6’s Fistula Maturity

6 weeks

6(5) mm deep

6 mm diameter

600 cc/min flow

6 cm cannulation zone

51 of 73

Create Maintain Salvage Abandon��Its all about the Tunneling

GRAFTS - materials

Bovine Carotid Artery -Artegraft

PTFE –Early Cannulation

Flixene, Acuseal, Vectra, Avflo

HeRO - venous outflow component

“If you think you’re too close to the skin...

you got it right!” John Ross MD Access GURU

52 of 73

Early Cannulation Grafts

¹

What is an Early Cannulation Graft

These are designed to reduce the complications of EC seen with standard grafts such as perigraft hematoma, seroma and infection. ²

What are the benefits?

The graft can be used immediately following placement
They are largely the same as grafts are largely the same in terms of placement, surgery, and qualifying patient profile ³

Are they available in my market?

There are many different types including: Flixene^TM, Acuseal^TM, Vectra^TM, and Avflo^{TM 2}
They are not widely available across the country and surgeon comfort with placing them varies
Partner with your local surgeons to see if they are available in your area

KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update in American Journal of Kidney Disease 75 (4, supplement 2), April 2020
Shakarchi, J. and Inston, N. Early cannulation grafts for haemodialysis: An updated systematic review, The Journal of Vascular Access, 20(2), 2019, 123-127. DOI: 10.1177/1129729818776571
Kingsmore, D.B., Stevenson, K.S., Richarz, S. et al. Patient characteristics predict patency of early-cannulation arteriovenous grafts. Sci Rep 11, 10743 (2021). https://doi.org/10.1038/s41598-021-87750-6

52

53 of 73

Structure: Middle graft layer

Elastomeric membrane middle graft layer

Benefits of middle graft layer design

Low-bleeding, enabling early cannulation within 24 hours of implantation
Reduces or avoids CVC reliance, reducing CVC stenosis, infections and associated costs vs. standard grafts ^1,2
Decrease the risk of hemodialysis cannulation needle and suture line bleeding³
Decrease seroma development by minimizing fluid passing through the graft wall ⁴

Information and images used with permission by Gore Medical.
.

¹ Mohapatra A, Yuo TH, Lowenkamp MN, et al. Cost-effectiveness analysis of immediate access arteriovenous grafts versus standard grafts for hemodialysis. Journal of Vascular Surgery. In press.

² Wagner JK, Dillavou E, Nag U, et al. Immediate-access grafts provide comparable patency to standard grafts, with fewer reinterventions and catheter-related complications. Journal of Vascular Surgery 2019;69(3):883-889.

³ Post Post hemodialysis needle removal apply 10-15 minute digital pressure to achieve hemostasis

⁴ Glickman MH, Burgess J, Cull D, Roy-Chaudhury P, Schanzer H. Prospective multicenter study with a 1-year analysis of a new vascular graft used for early cannulation in

patients undergoing hemodialysis. Journal of Vascular Surgery 2015;62(2):434-441. http://www.sciencedirect.com/science/article/pii/S0741521415003651.

53

54 of 73

Create Maintain Salvage Abandon��Inflow Outflow Conduit

GRAFTS - configuration

FA loop BA-BV

FA straight RA-CV/MC

UA loop – proximal or distal

UA curved

HeRO – BA-VOC

Chest loop/necklace

Thigh loop

55 of 73

Catheters

Right Atrium intended tip location

R over L- less vein contact

Tip type – split, palindrome, step

Retrograde/antegrade tunnel

First use phenomenon

Catheter exchange – fibrin sheath

Inside Out – Surfacer HeRO VOC

56 of 73

57 of 73

Create Maintain Salvage Abandon��Inflow Outflow Conduit

MAINTENANCE - average 1.8/year

Angioplasty

DCB InPact AV, Lutonix, Paclitaxel

Covered Stents- Covera, Viabahn, Fluency Plus Wrapsody

Revision for ulceration, aneurysm, steal

58 of 73

Fistulagram and angioplasty

59 of 73

Fistulagram and angioplasty

60 of 73

Left Forearm Radial Cephalic Fistula

What do you want to know?

What to do?(If anything)...

History

decreased access flow
decreased clearance(Kt/V)
difficult cannulation

Physical exam

Aneurysm?
Ulceration?
Thrill
Bruit
Circulation
Straight arm raise
Collateral veins
Edema

61 of 73

Create Maintain Salvage Abandon��Inflow Outflow Conduit

SALVAGE

Declot

TPA, Angiojet, Cleaner

Stents

Revision

ABANDON

62 of 73

Challenges and complications

Steal - DASS Dialysis Access Steal Syndrome

Neuropathy peripheral, CTS, IMN

Aneurysms

Pseudoaneurysms

Infection

PD and tunnel catheter malfunction

63 of 73

DASS �Dialysis Access Steal Syndrome

Arterial study – PAD

PAI – Proximalization of the Arterial Inflow

DRIL – Distal Revascularization Interval Ligation

RUDI – Revision Using Distal Inflow

DRAL – Distal Radial Artery Ligation

Banding – Central, Precision

Ligation

64 of 73

Proximal Radial Artery�Anastomosis�PRA

Avoid steal in upper arm fistulas by using the PRA(or PUA)

65 of 73

66 of 73

High Flow AV Access �Long-term Cardiac Concerns - Pulm HTN

Banding – Central, Precision

RUDI – Revision Using Distal Inflow

PAI – Proximalization of the Arterial Inflow

Ligation

67 of 73

68 of 73

Dialysis Access Center - Why?

CENTRALIZED CARE

COMPREHENSIVE CARE

QUALITY & SAFETY

SERVICE

davidbjerken@gmail.com 843-443-5784

69 of 73

70 of 73

71 of 73

Valuable Resources

VASA Vascular Access Society of the Americas May 20-23 SLC
CIDA Controversies in Dialysis Access October 29-31 DC
ISPD - ispd.org International Society for Peritoneal Dialysis - Guidelines
ASDIN – American Society of Diagnostic and Interventional Nephrologists
PD University - USF and ISPD didactic and hands on training
SAGES Guidelines for Laparoscopic PD Access 2014 and 2023 update
KDOQI CPG for Vascular Access 2019
Vantive/Baxter https://www.pdempowers.com/hcp/academy/educational-modules
JVA - Journal of Vascular Access
Merit and Mozarc/Medtronic - hands on training courses
Calculate by QxMD app
OpenEvidence app
davidbjerken@gmail.com (843)443-5784

Information per Dr. Bjerken’s experience and expertise

71

72 of 73

Challenges:

Care is “shared” between GS, VS, IR, IN
GS and VS resident/fellow case numbers for PD and AV access are extremely low(VS median = 0)
Historically the quality of PD surgical technique suffers from deficits in training and volume

Training and Education for Dialysis Access Care(PD, HD)

Dialysis Access is truly a specialty of its own

Interventional Nephrology(IN) is a fellowship which is well established

Percutaneous PD and AVF by IR and IN are happening

There are organizations(VASA, ISPD, ASDIN) and meetings(VASA, CIDA, ASDIN) journals(JVA, PDI) and corporate support(DaVita, Vantive, Merit, Mozarc)

Training and Education in Dialysis Access Care - PD and HD

73 of 73

PAI

Proximalization of the
Arterial
Inflow