Interventional Nephrology: Principles and Practice

Contents
Contributors
1: Preoperative Evaluation: History
	Introduction
	Conscious Sedation
	Medications, Allergies, Preexisting Conditions, and Contraindications
	Hemodialysis Catheter Procedures
	Angiogram and Angioplasty Procedures
	Thrombectomy
	Stent Placement
	Fistula Salvage Procedure for Lack of Maturation
	Peritoneal Dialysis (PD) Catheter Placement
	References
2: Preoperative Evaluation: Physical Examination
	Introduction
	General Examination
	Examination of Dialysis Access
	Physical Examination Prior to Access Placement
	Physical Examination Prior to Interventional Procedures on Arteriovenous Fistulae and Early Fistula Failure
		Inflow Problems
			Augmentation Test
		Accessory Veins
	Late Fistula Failure
		Outflow Venous Stenosis
			Fistula Collapse or Arm Elevation Test
		Aneurysm Formation
		High-Output Heart Failure
		Distal Ischemia
		Thrombosed Access
	Physical Examination Prior to Interventional Procedures on Arteriovenous Grafts
		Determining the Direction of Flow
		Venous Stenosis
		Pseudoaneurysms
		Infections
		Thrombosed Access
	Physical Examination Prior to Interventional Procedures on Central Venous Catheters
		Central Venous Stenosis
		Infections
	Conclusions
	References
3: Admission After Intervention: When and Why
	Which Patients Require Hospitalization Before a Procedure?
	Procedures Requiring Inpatient Care
		Percutaneous Needle Biopsy of Kidney
		Vascular Dialysis Access Interventions
			Angiogram, Angioplasty, and Stent Placements
			Central Vein Catheter Placement/Tunneled/Port
			Peritoneal Dialysis [PD] Catheter Placement Using Fluoroscopy
			Peripheral Arterial Interventions
			Endovascular AVF Creation
	Recording Procedure-Related Complications [PRC]
	Conclusion
	References
4: Communicating Effectively for Interventional Nephrologists
	Introduction: Why a Chapter on Communication in an Interventional Text?
	What Is Good Communication and How Does It Impact Care?
	Strategies for Excellent Communication
	Active Listening
	Use of Questions
	Feedback Model
	Communicating with Referral Sources
		The Patient
		Nephrologists
		Surgeons
		Dialysis Units
		Payers
		Organizational Communication
	Conclusion
	References
5: Anticoagulants and Thrombolytics
	Introduction
	Heparin
	Bleeding Risk During Interventional Procedures
	Dialysis Catheter Procedures
	Heparin-Induced Thrombocytopenia
	Planning Interventions in Patients Receiving Warfarin
	Warfarin to Prevent Thrombosis of Dialysis Accesses
	Newer Anticoagulant Medications
	Thrombolytics
	Summary and Recommendations
	References
6: Noninvasive Screening and Testing for PAD in CKD Patients
	Introduction
	Pathophysiology of PAD in CKD
	Epidemiology of PAD in CKD Population
	Noninvasive Screening Methods
		Physical Exam and History
		Noninvasive Testing
		Invasive Testing
	References
7: Overview of PAD Treatment in the CKD Population: Indications, Medical Strategies, and Endovascular Techniques
	Introduction
	Indications
	Medical Treatment of PKD
	Invasive Diagnostics of PKD
	Interventional Approach
	Precautions
	Conclusion
	References
8: Unconventional Venous Access: Percutaneous Translumbar and Transhepatic Venous Access for Hemodialysis
	Introduction
	Catheter-Based Hemodialysis
	Patient Selection
		Indications
		Contraindications
	Technique
		Translumbar IVC Catheter Placement
		Transhepatic Catheter Placement
	Complications
	Conclusion
	References
9: Approach to a Nonfunctioning Catheter
	Introduction
	Initial Evaluation and Treatment
	Diagnostic Evaluation in an Interventional Suite
	Interventions Directed at Specific Causes of Catheter Dysfunction
		Catheter Damage
		Catheter Kinking
		Tip Malposition
		Catheter Thrombosis
		Fibrin Sheath
			TDC Exchange
			Percutaneous Fibrin Sheath Stripping
			Angioplasty Disruption
			Internal Snare
		Central Vein Stenosis
	References
10: Approach to the Infected Catheter
	Introduction
	Background
	Risk Factors for Infection
		Mechanisms of Infection
		Suspecting an Infection
		Diagnosis of Suspected Catheter-Related Bloodstream Infection (CRBSI)
	Management of Confirmed Infections
		Catheter Management
		Identifying the Organism
		Duration of Antibiotics
	Prevention
		Sterile Technique in Placement of Catheter
		Vascular Access Team
		Antibiotic Impregnated Catheters
		Daily Handling
		Exit-Site Care
		Catheter Lock
		Scheduled Catheter Exchange
	Summary
	References
11: Approach to Patient Referred for Vascular Mapping
	Introduction
	The Techniques
	Physical Examination
	Ultrasound Examination
		Arterial Examination
		Venous Examination
	Angiography
	CO2 Angiography
	Which Technique Should Be Used?
		Physical Exam
		Ultrasound (US)
		Angiography
	Summary and Future Directions
	References
12: Approach to Arteriovenous Access
	Introduction
	Types of Vascular Access
		AV Fistulae (AVF)
		Synthetic Arteriovenous Grafts (AVG)
		Tunneled Cuffed Hemodialysis Catheters (TDC)
	Pre-dialysis Evaluation
		Timing of AVF Creation
		Patient Evaluation Prior to Access Placement
			Arterial Evaluation
			Venous Evaluation
	Alternative Strategies for Arteriovenous Fistula Creation
	Endovascular AVF Creation (Endo-AVF)
	Factors Related to Successful Fistula Use
	Assessment of AV Access by Physical Examination
		Special Considerations Related to AVG Examination
			Detection of Direction of Flow
			Detecting Recirculation
			Diagnosis of Venous Stenosis
	Secondary AV Fistula Creation
	Conclusions
	References
13: Approach to a Patient with Non-maturing AV Fistula
	Introduction
		Failure to Mature (FTM): Definition
		Risk Factors for Failure of Maturation
		Causes of Early Fistula Failure
			Inflow Problems
			Outflow Problems
		Identification and Management of Early AVF Failure
		Specific Interventions
	Angioplasty
	Accessory/Branching Vein Ligation
	Sequential Dilation
	Surgical Techniques
	Stents in AV Access
	Thrombectomy
	Prevention of Early FTM
	Conclusion
	References
14: Approach to an Arteriovenous Access with a Faint Thrill
	Segments of an Arteriovenous Fistula
	Physical Examination of an Arteriovenous Fistula
		Normal Findings
		Augmentation Test
	Etiology of a Faint Thrill
	New AVF
	Established AVF
	Summary
	References
15: Approach to an Arteriovenous Access with Hyperpulsatile Pulse
	Defining Hyperpulsatile Pulse
	Etiology of Hyperpulsatile AVF
	Clinical Findings Associated with Hyperpulsatile AVF
	Arm Elevation Test
	Thrill
	High-Pitched Bruit
	Prolonged Bleeding
	High Dialysis Venous Pressures
	Development of Aneurysm
	References
16: Approach to an Arteriovenous Access with No Thrill, Bruit, or Pulse
	Introduction
	Clinical Considerations
	Precautions
	General Approach
	Specific Approach
		Initial Cannulation
		Cross the Vein-Graft Anastomosis
		Perform Central Venography
		Administer Medications
		Treat Clot
		Angioplasty of Vein-Graft Anastomosis
		Remove Arterial Platelet-Fibrin Plug
		Evaluate Arterial Inflow
		Evaluate Venous Outflow
		Perform Completion Angiogram
	Autogenous Fistula Thrombectomy
		Anatomy
		Anastomosis
		Lesions
		Thrombectomy
		Angioplasty
		Clot Volume
	HeRO® Graft Thrombectomy
		Removal of Thrombus
		Angioplasty
		Anticoagulation
	Summary
	References
17: Approach to Patient with Arteriovenous Access Presenting with Hand Pain
	Introduction
	History-Taking
		Neurogenic Pain
		Vascular Pain
		Musculoskeletal Pain
	Physical Examination
	Differential Diagnosis and Pathophysiology
		Ischemic Monomelic Neuropathy
		Distal Hypoperfusion Ischemic Syndrome
	Investigations
		Ultrasonography
		Hemodynamic Studies
		Catheter-Based Contrast Arteriography
		Imaging Using Computed Tomography Angiography (CTA)
		Electrophysiology Study
		Management
		Flow Reduction Intervention
		Reconfiguration of the AV Access
		Distal Revascularization with Interval Ligation (DRIL)
		Revision Using Distal Inflow Procedure (RUDI)
		Proximalization of Arterial Inflow
		Ligation
		Prevention of DHIS
	Conclusion
	References
18: Central Venous Stenosis
	Management of Central Venous Stenosis
	Conclusion
	References
19: Approach to a Patient with Pseudoaneurysm
	Introduction
	Pseudoaneurysm Development
	Clinical Features
	Diagnosis
	Management
	References
20: Approach to Chest Pain During Dialysis
	Introduction
	Initial Evaluation of Chest Pain
	History-Taking
		Nature and Location of Pain
		Radiation of Chest Pain
		Timing of Chest Pain
		Associated Symptoms
		Vascular Access
	Physical Examination
	Differential Diagnosis and Pathophysiology
	Diagnostic Approach to Chest Pain
	Management
		Coronary Artery Disease
			Interventional Therapy for Coronary Artery Disease
			Medical Therapy for Coronary Artery Disease
		Subclavian Coronary Steal Syndrome
			Technical Details
	Conclusion
	References
21: Approach to Cyanotic Digits and Hand Paresis
	Introduction
	Cyanotic Fingers and Hand Ischemia
	Management
	Ischemic Monomelic Neuropathy (Nerve Injury)
	Summary
	References
22: Approach to an Abnormal Surveillance Measurement
	Introduction
	Vascular Access Monitoring
	Vascular Access Surveillance
		Intra-Access Flow Measurement
		Access Pressure
		Duplex Ultrasonography
	National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) VA Guidelines
	Conclusion
	References
23: Arterial Stenosis Affecting Arteriovenous Fistulae and Grafts in Hemodialysis Patients: Approach to Diagnosis and Management
	Introduction
	Definition, Epidemiology, and Pathophysiology
		Definition of Arterial Stenosis
		Epidemiology of Arterial Stenoses
		Pathophysiology of Arterial Stenoses
	Initial Evaluation
		History
		Physical Examination
		Hemodynamic Parameters of Hemodialysis Vascular Access
		The Importance of Prior Imaging Studies
		Diagnosis Requires a High Index of Suspicion
		Preventative Measures
	Differential Diagnosis
	Diagnostic Studies
		Overview
		Noninvasive Studies
			Ultrasound
			CT
			MR
		Conventional Angiography
	Classification of Arterial Lesions
		Overview
		Anastomotic and Juxta-anastomotic Lesions
		Central and Feeding Artery Lesions
		Distal Artery Lesions
		Lesions due to External Compression
	Management
		Percutaneous Transluminal Angioplasty
		Stents
			Stent Varieties
		Angiographic Approach
		Anticoagulation
	Conclusion
	References
24: Approach to the Patient with Suspected Renal Artery Stenosis
	Introduction
	Ischemic Nephropathy
	Defining the Controversy
	Approach to Diagnosis and Intervention
	Diagnostic Angiography
	Intervention
	Conclusion
	References
25: Vascular Injury During Interventions
	Introduction
	Historical Perspective
	Epidemiology
	Pathophysiology
	Differential Diagnosis
	Clinical Management
	Outcomes
	Newer Gene and Pharmaceutical Management
	Conclusion
	Bibliography
		Other References
26: Pulmonary Embolism Associated with Dialysis Access Procedure
	Introduction
	Pulmonary Protective Features
		Double Circulation
		Fibrinolysis
	Types of Emboli
		Microemboli
		Paradoxical Emboli: Microemboli
		Macroemboli
			Paradoxical Emboli: Macroemboli
		Massive Emboli
	Concerns Related to PE
		What Makes an Embolus Lethal?
		How Much Is Too Much?
		How Should Excessive Clot Load Case Be Managed?
		What Happens to the Embolic Thrombus?
	Management of PE
		Risk Stratification
		Using Risk Factor Data
		Diagnosis
		Plasma D-Dimer
		Radiological Tests
			Ventilation-Perfusion Scintigraphy
			Computed Tomography (CT)
		Treatment of Pulmonary Embolization
			General
			Mechanical Thrombectomy Devices
			Surgical Embolectomy
	References
27: Stent Migration
	Introduction
	Case Report
	Factors Affecting Migration
	Complications Related to Stent Migration
	Management
	Techniques Used to Retrieve Stents
		Dual Snare Technique Through the Same Sheath
		Single Snare Technique
		Monorail or Co-axial Technique
		Balloon-Mounted Snare Technique
		Glide Wire Loop and Snare
		IVC Filter Placement
		Wait and Watch Policy
	Short-Distance Migration
	Other Medical Devices
	Case Outcome
	Conclusion
	References
28: Foreign Body Retrieval
	Introduction
	Types of Intravascular Foreign Bodies
	Localization of Foreign Body
	Complications of Foreign Bodies
	Indications/Contraindications for Foreign Body Removal
	Equipment and Devices for Foreign Body Retrieval
		Baskets
			Description of Dotter Retrieval Basket
		Foreign Body Retrieval Forceps
			Types of Retrieval Forceps
	Dialysis Access-Specific Case Scenarios
	Coding
	Conclusion
	References
29: Contrast and Medication Adverse Reactions
	Clinical Vignette
	Introduction
	Classification of Radio Contrast Agents
	Pharmacokinetics
	Incidence
	Classification of Adverse Reactions
	Immediate Reactions
		Allergic-Like Reactions
		Physiologic Reactions
	Risk Factors
	Delayed Reactions
	Risk Factors
	Iodide Mumps
		Clinical Vignette
	Acute Polyarthropathy
		Seafood Allergy and Contrast Media
	Prevention of Adverse Reactions
	Treatment of Reactions
	Conclusion
	Bibliography
30: The Management of Serious Adverse Events Associated with Interventional Procedures
	Introduction
	Procedure-Related Complications (PRC)
		Introduction
		PRCS Related to Catheter Procedures
	Hemorrhage
		Management of Tunnel Bleeding
	Pneumothorax
		Asymptomatic Pneumothorax
		Symptomatic Pneumothorax
	Venous Air Embolism (VAE)
		Clinical Manifestations
		Pathophysiology
		Management
	Paradoxical Air Embolization
	Perforation of a Central Vein
		Acute Perforation
		Delayed Perforation
		Management of Central Vein Perforation
	Cardiac Perforation
	Arterial Perforation
		Management
	PRCS Related to Arteriovenous Access Procedures
		Venous Rupture
			Subclinical Extravasation of Contrast (SEC)
			Grade 1 Extravasation
			Grade 2 Extravasation
			Grade 3 Extravasation
			Incidence by Grade
		Arterial Embolization
			Signs and Symptoms
		Pulmonary Embolization
	Sedation/Analgesia-Related Complications (SARC)
		Introduction
		Agents Used
			Midazolam (Versed)
			Fentanyl (Sublimaze)
	Precautions
		Pre-procedure
		Intra-Procedure
		Post-Procedure
			SARCs
		Hypotension
		Drop in Oxygen Saturation
	Hypersensitivity Drug Reactions (HDR)
		Introduction
		Types of Radiocontrast Media (RCM)
		Reactions to RCM
		Signs and Symptoms of Immediate Hypersensitivity Reactions
		Pathogenesis
			Urticaria
			Angioedema
		Risk Factors
		Treatment
			Preparedness
		Prompt Recognition
		Management
			Therapeutic Agents
		Epinephrine
			Management Strategies
			Biphasic Reactions
			Prevention
				Emergent Procedures
				Recommendations
	References
31: Preoperative Evaluation of a Patient for Peritoneal Dialysis Catheter
	Introduction
	Procedure-Related Risk Assessment
	Patient Risk Assessment
	Management of Comorbidities
	History
	Physical Exam
	Laboratory Testing
	Hemostasis and Management of Anticoagulation
	Assessment of Thrombotic Risk
	Assessment of Bleeding Risk
	Assessment to Evaluate for Interruption and Bridging of Anticoagulation
	Patient Preparation for Peritoneal Catheter Implantation
	Conclusion
	References
32: Operative Considerations for Peritoneal Dialysis Catheter
	Introduction
	Types of Current Chronic Peritoneal Catheters and Comparative Advantages
	Proper Location of Catheter Components
	Preoperative Evaluation and Ultrasound Imaging of the Abdominal Wall
	Placement Technique Overview
		Blind Placement by Tenckhoff Trocar
		Dissection (Surgical)
		Laparoscopic Placement, with Omentopexy and Long Rectus Tunnel Options
		Peritoneoscopic Placement
		Fluoroscopic Placement
		Blind (Seldinger) Technique
		Relative Success of Placement
		Techniques
	Embedding PD Catheters and Exteriorizing
	Catheter Repositioning
	Repair of Pericatheter Leaks and Hernias
	Catheter Removal
	Ultrasound Examination of Existing PD Catheters
	References
33: Approach to a Patient with Bowel Perforation
	Introduction
	Etiology and Nature of Perforations
	Diagnosis
	Management
	Strategies to Minimize the Risk of Perforations
	Summary
	References
Index