Thrombosis focus and dialysis discussion at first CX renal interventions session


The renal interventions session at Charing Cross (CX) Symposium 2023 (25–27 April, London, UK) yielded a rich vein of education and audience participation on everything from stent positioning to interventional training. With speakers including Matthew Gibson (Berkshire Imaging, Reading, United Kingdom) and Robert Shahverdyan (Asklepios Kliniken Hamburg, Hamburg, Germany), its talks provided a wide snapshot of the renal space. 

Shahverdyan opened the session by presenting on a new endovascular arteriovenous fistula (endoAVF) device, the Velocity system (Venova Medical). Setting out a few of the challenges in dialysis access, he said that endoAVFs can pose particular challenges—including the fact that “not all patients have appropriate anatomy” and, centrally, the risks of juxta-anastomotic stenoses, partial deep venous flow and associated cannulation difficulties. The Velocity system, Shahverdyan averred, is the only endoAVF system “that would replicate surgical AVF (sAVF) anatomy”, offering as it does an end-to-side connection from the proximal radial artery to the perforator vein “without losing any flow into the deep venous system”. Citing the first-in-human VENOS trial results on the technology, he said that early use of the system “demonstrates clear proof” of its ability to improve vascular access care.  

One early presentation by Gibson set out “a real-world approach” to managing thrombosed haemodialysis access. Clotted access is usually preventable, Gibson said, and can be due to a “failure”. This failure could be the surgical or radiological formation technique, monitoring needling technique or homeostasis (dehydration/hypotension), Gibson added. He also established the particular problems raised by clotted access. Compared to a preventative fistulopasty, he said, a declotting procedure results in a worse patient experience, worse success and complications rates, and was more time- and resource-consuming. It also potentially poses the need for temporary access if delayed or unsuccessful.  

But, he asked, what should you do when presented with access thrombosis? First, he urged listeners to “act quickly and effectively” to remove a thrombus and to treat the culprit lesion. Though there are a range of techniques available, there are no randomised controlled trials to guide choice of technique. While there have been meta-analyses performed, Gibson argued that there is “no clear winner” on the issue. This is where real-world considerations could help to expedite a decision.  

In the real world, he said, clinical decision-making during the COVID-19 pandemic changed to favour methods that were both the least invasive and most likely to be successful—as well as less resource-intensive. He noted that this had led to a fall in declotting procedures, especially surgical declotting, per a report on access management during the pandemic published in the Journal of Vascular Access by Christopher Seet (Barts Health NHS Trust, London, United Kingdom) et al in 2021. Gibson’s concluding message was to “treat [thrombosis] quickly and effectively, but be realistic and think of the future”. He added that technique is “less important than availability, skill and enthusiasm”.  

Also presenting was Georgia Georgopoulou (University Hospital of Patrai, Patras, Greece), who detailed the Nephrology Partnership for Advancing Technology in Healthcare (N-PATH) interventional nephrology training programme. She described it as “the first European advanced training course in diagnostic and interventional nephrology”, explaining that it comprises component modules in molecular pathology, vascular access, medical ultrasound and peritoneal dialysis, each with hands-on training sessions in cities across Europe including Milan and Prague, while also including online educational resources.

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