AVF狭窄に対するPTAへの科学的アプローチ Low …...

第18回日本アクセス研究会 ランチョンセミナー（メディコン)

2014年11月30日（日） 12：15～13：15 あわぎんホール 第1会場

AVF狭窄に対するPTAへの科学的アプローチ ～Low Pressure Techniqueの 可能性を検証する～

池田バスキュラーアクセス・透析・内科クリニック

池田 潔

図3A 動脈圧と血管径の同時記録例

佐藤隆幸 著 「血管の粘弾性」

図3B 動脈圧－血管径関係を示すリサージュプロット

佐藤隆幸 著 「血管の粘弾性」

4 atm.

6atm.

Mean =3.67mm

Mean =4.23mm

Ｓalt Lake City Utah 23-24 2014

Multiple Repeated Low Pressure Technique

IKEDA Vascular access dialysis

Internal Medicine clinic

Tohru Yasuda , Kiyoshi Ikeda

CIDA

0

10

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90

100

0 50 100 150 200 250 300

きかん

(days)

(%)

Incomplete ballooning 412 cases

AVF Patency rate 2003 ～2010

0

10

20

30

40

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60

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0 50 100 150 200 250 300

NS

きかん

Complete ballooning 567 cases

(days)

(%)

Incomplete ballooning 412 cases

AVF Patency rate 2003 ～2010

40

50

60

70

80

90

100

0 50 100 150 200 250 300

NS

きかん

Complete balloning 567 cases

(days)

(%)

Incomplete ballooning 412 cases

AVF Patency rate 2003 ～2010

Dr.Sato et al Complete 62% 25%

Incomplete 80% 27%

3M 6M

New Low Pressure Technique (LPT)

Pre PTA

2atm x 30sec

3atm x 30sec

4atm x 30sec

6atm x 30sec

7atm x 30sec

8atm x 30sec

Post PTA

①New Low Pressure Technique (LPT) is an attempt to maximize blood flow rate when using maximum pressure is not an option. ②In this example of LPT we take a balloon rated to 15atm but only using it up to its nominal pressure of 6atm. Beginning at 1atm and expanding and contracting the balloon 20 to 25 times a minute while increasing the pressure by 1 atm every minute up to the nominal pressure of 6atm. Total time is 6 minutes and in some cases slight more time. ③Balloon expansion is gradually increased during the first 5 minutes to full vein size in the final minute. ④This method applies to all balloon pressures and is used accordingly based on the balloon's rated pressure and nominal pressure. One of the goals of this technique is to achieve full expansion at low pressure.

※Super-non-compliant balloon (CONQUEST®, Yoroi®)

Super-non-compliant balloon vs Others

Super-non-compliant Balloon

As shown in the figure, group A, using a super non-compliant balloon eliminates the occurrence of dog bone phenomenon. Vein damage is also avoided because the balloon is limited in its expansion.

Dog-bone phenomenon

As shown in the figure, group B, when using a semi-compliant balloon that looks like it is being bitten by a dog, causes intimal injury and the main objective is not achieved due to the fact that the balloon expands beyond the optimal size.

7atm 6atm

第2回 九州バスキュラーアクセスライブフォーラム2014

熊本・福岡メイン会場にて

サテライト会場を

九州５か所に設置し開催

頻回低圧拡張法 実演 第2回九州バスキュラーアクセスライブフォーラムにて（2014.11.9）

Compliant balloon at 14atm

Conquest at 10atm

Lt. AVF

Japanese medical treatment covered by health insurance

・Only 1 PTA / 3 months

・Only 1 balloon

・Stent usage not permitted

in Fukuoka area

・stretching gradually

・repeated 10 times /30sec

Flow volume＜400ml/min Pulsasion Index ＞1.2 Stenosis diameter＜1.0mm

Lt. AVF

stenosis

・Flow volume 300ml/min ・Pulsasion index 2.0 ・Stenosis diameter 0.8mm

Case 1

Conquest at 2atm / 30sec

Conquest at 4atm / 30sec

Conquest at 6atm / 30sec

Conquest at 6atm / 90sec

After PTA

・Flow volume 300→500ml/min ・Pulsasion index 2.0→1.0 ・Stenosis diameter 0.8→2.9mm

before

・Flow volume 360ml/min ・Pulsasion index 1.6 ・Stenosis diameter 1.6mm

Lt. AVF Case 2

Conquest at 10atm / 120sec

・Flow volume 360→500ml/min ・Pulsasion index 1.6→1.2 ・Stenosis diameter 1.6→3.2mm

After PTA

before

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100

0 50 100 150 200 250 300

AVF Patency rate - using Conquest -

(days)

(%)

41 cases

Average pressure 8.8atm Average balloon size 5.1mm

70% 3M

6M 30%

Repeated low pressure technique is effective method for expanding without rupture. Dog-bone phenomenon can be avoided by using super-non-compliant balloon.

Conclusion