Hello. My name is Christopher smith. I'm sorry to be absent today. Product of an untimely encounter with our viral photo. This talk will introduce you to novel approaches for arterial venus house officially I have no conflicts of interest to disclose scope of the problem in the United States is massive. Nearly 800,000 people within stage real disease, Roughly 2/3 on dialysis And 1/3 with a transplant. The $50 billion in E. S. R. D. And $70 billion in CKD Accounts for nearly 16% to $741 billion dollars Of Medicare spending in 2018. The overwhelming majority of patients with dialysis in the United States start with a catheter, Roughly 20% have official or a graph and progress. Only 20% of new starts are with officially ready for use without any catheter at all. The problem is correlated with the absence of prior nephrology care. More than 80% of new starts over the Catheter. That is in the setting of no prior nephrology care. If prior nephrology care has been established one year prior to HD start, this translates into reducing that number two, approximately 50%. Only about one third of the roughly 47 million patients in the US with CKD have established nephrology care And patients established on dialysis. The prevalence of an arteriovenous official is approximately 67%. A little more than 80% of patients are using some type of arteriovenous access. Still this number has not changed over the last decade. 16- 80% of all dialyzers patients are dialyzers with an indwelling Catheter. The prevalence of a functional arteriovenous official increases over the first year after initiation of dialysis. This number of plateaus relative to the total number of prevalent patients on dialysis, it increases. This is due to the attrition of patients. The effect of MS dialysis is significant and is associated with increased hospitalization. Intuitively, the more dialysis missed the worse the effect. This also translates into increased mortality. More Dallas dismissed. The greater the effect on mortality morbidity and mortality of patients on hemodialysis is correlated with the mode of access. All cause mortality, fatal and non fatal infection. Major cardiovascular events and hospitalization are all worse In patients with catheters. In comparison to patients with fisheries, the relative risk of all cause mortality, fatal and non fatal infection, cardiovascular events and hospitalization are also increased when comparing catheter to graphs. When comparing graphs to official list, there is still a difference in outcomes when it comes to all cause mortality, fatal and non fatal infection and hospitalization. Although not much of a difference in cardiovascular events. So it is logical that we do well to endeavor to create usable and sustainable officials and patients needing chronic renal replacement therapy if official of surgery capitalizes on one of two actual veins in the arm. The sofa like vain or the basilica vein surgical connections between these veins and arterial inflow can be rendered at a finite number of locations. In order to afford readily available access to high blood flow circuits that can be readily. Kanye lated, one needle would go to the machine and the other needle returns to the patient. These need to be reliable and reproducible so that the patient can receive dialysis typically three times a week for several hours according to the prescription for dialysis. Sbs guidelines and surgical principles emphasize starting with an arterial beneficial for patients needing dialysis, placing the accesses distantly in the upper extremities as possible and giving preference to the non dominant arm. There is a rule of six is the access should achieve a minimum six millimeter diameter six centimeters of usable length for double nina accumulation to avoid recirculation of dialyzers and non dialyzers blood Less than six deep from the skin service to allow for accurate needle placement by techs and nurses And achieving a flow volume of about 600 MS or more per minute in order to sustain enough flow through the circuit to achieve sufficient clearance of solute and water. Still, you can see that the primary patsy of a surgical official is limited, although arteriovenous specialists do better in the long term than graphs. Long term pattern. See It's approximately 50%. This is a contemporary experience reported by wars at in the Netherlands, which is quite representative of what happens with a v access About 2/3 of radio stifling officials become functionally usable upper arm, officials fare better than radio stifling official is still requiring between one and two interventions per year to maintain usability and cumulative pattern. See arteriovenous grafts do well initially but fall off over time and require a larger number of interventions annually than auto genesis access to. And with such numbers accounting for our quote, good results. End quote out of necessity, invention is born today there are two commercially available per catania systems to create arteriovenous dialysis Specialist Endo A VF. The wavelength by bard and the ellipsis by medtronic. Each with its attributes. The wavelength system utilizes catheter access in the artery and vein, and magnetic bars are what married the vessels in close juxtaposition such that the R. F. Energy can be activated to create the endovascular arteriovenous connection, which is maintained by high flow, the catheter in the artery, the catheter in the vein, the activation, creating the art periodically slash anatomy. Work fistula, and then the high flow diversion into the vein from the artery which then travels through the perforated system into the superficial system, thereby rendering the arteriovenous fischelis usable for dialysis access here. You can see the two catheters juxtaposed in the artery and vein and then the subsequent arteriovenous fish. The diversion of flow from the deep system to this superficial system in the symbolic and median cubicle vein to the basilica system in the arm. As reported in the original neat trout which introduced the wave link endo A. B. F. There is a 98% technical success. 8% serious adverse events such as hematoma. An extra visitation, 12 month primary and cumulative patent c. 69 and 84% respectively, 64% of dialysis dependent patients were using their Perky Tania's official or dialysis as you will recall from the surgical arteriovenous fistula in points. The primary and secondary patents er quite respectable for the wavelength Endo Mdf. Alternatively, the ellipsis system by bar utilizes single venus access and needle entry from vein into radio artery. Under ultrasound guidance. The ellipsis catheter is then deployed and activated to create the enablement of the two vessels and then they are caribbean, especially joseph. Allen vein is the targeted system for the arterial ization. Primary potency of the two techniques is similar according to a retrospective comparison of cumulative patsy of the two techniques. The ellipsis appears to fare better than wavelength. This difference may be related to the key difference between the two techniques. Ellipsis is a direct communication or more direct communication between the radio artery and the superficial system. Whereas the wavelength requires some bridging veins between the ulnar or radial vein to the perforated the vein to the superficial system. Regardless, Endo a VF has increased the options available for patients needing him analysis access, providing another couple and atomic locations to create an arteriovenous anastomosis. So where does endo a VF fit in our armamentarium. In the V. A study by Pope leo 116 upper extremities. In 58 patients were evaluated by ultrasound for an atomic suitability for Endo aVF. Parenthetically meticulous ultrasound evaluation is essential in the identification and planning for suitable patients for Endo A BF. In this study, 31% of patients were deemed appropriate for a risk for radio symbolic baby fish. Roughly 2/3 of these patients were not candidates. Radio city officials of these remaining two thirds approximately half were not candidates for Endo A VF. By an atomic criteria of that roughly one third of limbs that were anatomically suitable for Endo A VF. Nearly equally, they were split amongst wavelength and ellipsis. Zarrella reported his retrospective experience and 35 patients who underwent wave link into a BF. 32 patients have follow up, there was 100% technical success procedure time was two hours with nearly 10 minutes of Flora Skopje time and 52 mls of contrast, utilized 1/4 of patients had complications, mostly minor. About 40% needed additional intervention. Similar to standard surgical a BF patients. 13% needed subsequent surgery with two converted to surgical arteriovenous. Officially Low volume was good. And the 23 patients on dialysis at three month. Follow up roughly half were using their endo a BF successful in summary analysis, dependence is a reality for a large number of people, reliable dialysis access translates into improved outcomes. Subcutaneous officially are feasible In many patients. An atomic and patient considerations influence both the surgical configuration and also the Per Catania's approach. Endo A VF, expands the options available to patients requiring hemodialysis access, and we are still in the early part of our experience in understanding how to best utilize this evolving strategy. I thank you for your time and attention. Stay well, mm hmm.