Tips & Tricks for AV Fistula & Graft Declots

[Neghae Mawla]
Aaron, you came and spent the day with me. What did you think?

[Aaron Fritts]
I was telling Chris some of the tricks that I picked up. One was the aspiration from the sheath as you're pulling the Fogarty back. That, I had never seen before, and I thought that was a really cool trick. It helped get some of that clot out. You showed how much clot you pulled out. I was used to always just putting the Fogarty back and then letting it flow with everything else, but I think that that makes a significant difference...The official speed by which you do it, and the techs all know your next move, I mean, that all makes a huge difference. Labs that only do [declots] once a month, that slows everything way down because they forget how to set everything up. They're just standing there and handing you wires and stuff, but I think part of it is just well trained staff.

[Neghae Mawla]
Staff makes a huge difference. We always underestimate how important the staff are.

[Aaron Fritts]
With imaging too, right? And then being able to do [the declot] without TPA using the devices. Chris and I trained similarly where I was training just Kumpe catheters, four milligrams of TPA, lace declot as you pull back and then go in and balloon macerate everything. Push it out. Pull with the Fogarty. But I mean, it felt like it took two hours to do a declot.

[Neghae Mawla]
That's the basic declot.

[Chris Beck]
I will say that I get bogged down. For some reason, if I get impatient, I start wanting to do more things myself. I'll start grabbing for things. I'm loading things up on the wire, and that's out of my frustration, but for declots, you really have to be a general. I'll tell my techs before we get started, I'm like, "I'm going to bark a lot of orders, and I'm going to expect you to be on your game. For declots, I really want to move fast." I really stay in one position and let everything come to me because whenever I start flailing around is when I think I get sloppy. The other thing that I learned from Aaron after he went and worked with you, Neghae, was the amount of polish that I'm putting on afterwards. Sometimes, I'm just going after every little small piece of clot. I was just like, "Oh, I don't have to do that," and then it was like someone took a burden off me.

[Aaron Fritts]
Either you watch this little piece of clot, and then you do a run two minutes later, and it's gone, because the flow helps get rid of it, right? You don't have to go in there and balloon every little piece of clot that's hanging on.

[Neghae Mawla]
I take the Fogarty towards the outflow as part of the polish stage... I like the over-the-wire Fogarty because I'll just inflate it and lock it. I'll polish or floss with it. If it goes all the way into the outflow, and I don't feel any resistance, it's fine. If the graft is not pulsatile, and the fistula is not pulsatile, you can get used to examining the fistula after each stage and each step that you do it, and see how that exam changes, because that will guide you also. Then suddenly, you get this great thrill, and all the resistance is gone. Everything feels great. Well, at that point, you can say, "All right, we're done.” You do a quick run to correspond with it, but that becomes a good guide for you also more than the images. If you've got clot, but it feels great, and it's just a little piece of clot that's hanging out, a lot of times... I think that's where my Voodoo for this extra 5,000 of heparin at the end comes in. That should take care of that.

[Chris Beck]
… In terms of getting my procedure time down, if I know which way is inflow and if I know which way is outflow, I will go ahead and place my seven Fr sheath with a seven to six venous and arterial respectively. I'm accessing with ultrasound. I get my seven Fr in, and then also get my six Fr in at the same time. That way, I've just taken care of the sheath work. I've taken care of most of my ultrasound work, and then I can just start going to work on the procedure. But in your situation, it sounds like you're always treating outflow, then coming back, doing inflow, and then polishing up the rest. Is that right?

[Neghae Mawla]
That's it. I will sometimes put in both sheaths just for no reason, but most of the time, before I put that second sheath in, I want to make sure that whole segment is cleared. If that sheath is there, then that slows down how long it takes me, or sometimes it gets in the way of me clearing it, especially if I'm using a rotational device. Balloon, you can do comfortably. You can balloon around the sheath, and it's fine, but if you're doing a rotational device, and that gets in the way, or if there's a wire there that gets in the way, that's why I don't put that second sheath in [immediately].

[Chris Beck]
Let's talk about lesions where you decide to stent. Taking extravasation off the table, which lesions and at what point do you decide to stent? When you are stenting, does it depend on location whether you're going to use bare metal versus stent graft?

[Neghae Mawla]
Always the stent graft. The data is there to show that the bare metal is just not that good. For me, it's always a stent graft, and I'm choosing between the Viabahn and the Covera. Usually, the costs are pretty comparable for me there. The Covera has a flared option, which I like, and so when you've got a graft, a seven millimeter that opens up into a 10 or 11 millimeter axillary, then the Covera there is actually what I prefer, because it opens up into that larger vein. But otherwise, I think the use of them are pretty much the same, but it really boils down to how resistant that lesion is. The other thing to keep in mind that's in the workflow now is the drug-coated balloons.

[Chris Beck]
Let's talk about the DCB's for the Dallas circuit. Do you use them during a declot, or do you declot and then bring them back if you have something that you want-

[Neghae Mawla]
No, if I want to do it, I'll use it during a declot. The problem with the DCB is that there's no reimbursement for it, but the advantages of both the Lutonix and the IN.PACT balloon is a 12-month guarantee that if I need to reintervene, they replace the balloon. It makes me feel better that, "All right, I've tried it, and it didn't work." No harm done that way. I think that actually is coming in before the stent graft. It's trying to figure out where that's going to fall into the algorithm, but I think normally I would say that falls into the algorithm before the stent graft does or should, particularly in lesions and in areas where we're cannulating and it's hard to stent. I don't like cannulating a stented region… I've seen too many stent fractures from that, so I try to avoid cannulating in the graft or in the fistula, where they're going to be using it. For there, I'll lean definitely towards the drug-coated balloon, but if I feel like it's resistant or going to come back, I will lean towards the DCB more on a repeat procedure than on a first procedure.

[Chris Beck]
Fair enough.

[Neghae Mawla]
Let's say I'm doing the declot, and it's their first time here, and I've got recoil like crazy. Then, stent graft can't be done because I'm afraid they're going to come back. Usually, let's say I've done it. I was happy with the outcome, but they come back two or three weeks, four weeks later. I will upsize it. Let's say they come back a third time within a month, because my final images look good, but they just are not holding. Then I'll say, "Okay, you know what? This is the scenario for a DCB."