Ari Kramer's guest appearances

Ari Kramer

BackTable Vascular & Interventional

David Sacks

John Martin

David Wood

David Kim

Karen Brown

Justin Lee

David Liu

Eric Keller

Preston Smith

David Ball

Mike Watts

Chris Thomson

Susan Jackson

John Lipman

Aaron Shiloh

OwlTail

In this episode, Dr. Chris Beck interviews vascular access surgeon Dr. Ari Kramer about his management of arteriovenous (AV) access for dialysis patients. We cover his preferred imaging for identifying and deciding to treat stenoses, the protracted angioplasty technique, and the evolution of research in drug coated balloons (DCB) and stent grafts.---CHECK OUT OUR SPONSORSMedtronic Chocolate PTA Balloonhttps://www.medtronic.com/peripheralBD Rotarex Atherectomy Systemhttps://www.bd.com/rotarex---SHOW NOTESDr. Kramer starts by describing his vascular access practice. He is the sole operator within a hospital-based practice where he creates and maintains AV access. When evaluating a patient for possible intervention, duplex ultrasound, physical exam findings, patient history, and information from the dialysis center all play roles in determining whether the patient is eligible for a fistulagram. Dr. Kramer offers fistulagram tips: he obtains access above the arterial anastomosis in order to avoid occlusion of outflow, and he first shoots contrast into the venous tract first and works his way up to the arterial system. Depending on the findings of the fistulagram, stenotic lesions in the venous outflow tract can be treated. Dr. Kramer generally treats the lesion if the stenosis limits flow by more than 50%. Additionally, he treats any lesion resulting in a luminal diameter of 2mm or less.In an AV fistula circuit, Dr. Kramer describes his procedure, which is largely informed by the most current clinical trials. He first employs the FLEX Vessel Prep system to reduce circumferential fibromuscular tension. Next, he performs protracted plain old balloon angioplasty (POBA) for 90 seconds. This helps Then, he re-images the vessel to ensure there was no injury and utilizes a DCB to deliver paclitaxel. We discuss the clinical trials outcomes of the two current DCBs that have been approved for use in AV management, IN.PACT and Lutonix. Dr. Kramer also notes the significant cost of DCBs and lack of access to treatment for the most at-risk patients. He encourages clinicians to unite to advocate for increased reimbursement for this treatment that has been proven to show the highest standard of care.Additionally, we address treatment of non-autogenous AV circuits with stent grafts. Dr. Kramer prefers self-expanding covered stents, such as Viabahn or Covera, since they are conformable and resistant to kinks. Overall, Dr. Kramer emphasizes the importance of the operator staying up to date on clinical trials that show data for diverse tools with various indications, knowing their own skill and comfort, and incorporating the best treatments based on their patient and practice context.---RESOURCESEp. 139 AV Fistula Graft Management:https://www.backtable.com/shows/vi/podcasts/139/av-fistula-graft-maintenanceFLEX Vessel Prep System:https://www.venturemedgroup.com/KDOQI Clinical Practice Guideline for Vascular Access, 2019 Update:https://www.ajkd.org/article/S0272-6386(19)31137-0/fulltextFahrtash, F., Kairaitis, L., Gruenewald, S., Spicer, T., Sidrak, H., Fletcher, J., Allen, R., &amp; Swinnen, J. (2011). Defining a significant stenosis in an autologous radio-cephalic arteriovenous fistula for hemodialysis. Seminars in dialysis, 24(2), 231–238.Haskal, Z. J., et al. (2010). "Stent graft versus balloon angioplasty for failing dialysis-access grafts." New England Journal of Medicine 362(6): 494-503.Bard Peripheral Vascular. Covera vascular covered stent instructions for use. Rev.4 / 08-18.http://www.bardpv.com/eifu/uploads/BAWB05872R4-Covera-Vascular-Covered-Stent-IFU.pdf.The Fight Doctors:https://thefightdoctors.com/about/Find this episode on BackTable.com for all resources mentioned in this podcast, including references to journal articles.

In this episode, Dr. Chris Beck interviews vascular access surgeon Dr. Ari Kramer about his management of arteriovenous (AV) access for dialysis patients. We cover his preferred imaging for identifying and deciding to treat stenoses, the protracted angioplasty technique, and the evolution of research in drug coated balloons (DCB) and stent grafts. --- CHECK OUT OUR SPONSORS Medtronic Chocolate PTA Balloon<a href="https://www.medtronic.com/peripheral" rel="nofollow" target="_blank">https://www.medtronic.com/peripheral</a> BD Rotarex Atherectomy System<a href="https://www.bd.com/rotarex" rel="nofollow" target="_blank">https://www.bd.com/rotarex</a> --- SHOW NOTES Dr. Kramer starts by describing his vascular access practice. He is the sole operator within a hospital-based practice where he creates and maintains AV access. When evaluating a patient for possible intervention, duplex ultrasound, physical exam findings, patient history, and information from the dialysis center all play roles in determining whether the patient is eligible for a fistulagram. Dr. Kramer offers fistulagram tips: he obtains access above the arterial anastomosis in order to avoid occlusion of outflow, and he first shoots contrast into the venous tract first and works his way up to the arterial system. Depending on the findings of the fistulagram, stenotic lesions in the venous outflow tract can be treated. Dr. Kramer generally treats the lesion if the stenosis limits flow by more than 50%. Additionally, he treats any lesion resulting in a luminal diameter of 2mm or less. In an AV fistula circuit, Dr. Kramer describes his procedure, which is largely informed by the most current clinical trials. He first employs the FLEX Vessel Prep system to reduce circumferential fibromuscular tension. Next, he performs protracted plain old balloon angioplasty (POBA) for 90 seconds. This helps Then, he re-images the vessel to ensure there was no injury and utilizes a DCB to deliver paclitaxel. We discuss the clinical trials outcomes of the two current DCBs that have been approved for use in AV management, IN.PACT and Lutonix. Dr. Kramer also notes the significant cost of DCBs and lack of access to treatment for the most at-risk patients. He encourages clinicians to unite to advocate for increased reimbursement for this treatment that has been proven to show the highest standard of care. Additionally, we address treatment of non-autogenous AV circuits with stent grafts. Dr. Kramer prefers self-expanding covered stents, such as Viabahn or Covera, since they are conformable and resistant to kinks. Overall, Dr. Kramer emphasizes the importance of the operator staying up to date on clinical trials that show data for diverse tools with various indications, knowing their own skill and comfort, and incorporating the best treatments based on their patient and practice context. --- RESOURCES Ep. 139 AV Fistula Graft Management:<a href="https://www.backtable.com/shows/vi/podcasts/139/av-fistula-graft-maintenance" rel="nofollow" target="_blank">https://www.backtable.com/shows/vi/podcasts/139/av-fistula-graft-maintenance</a> FLEX Vessel Prep System:<a href="https://www.venturemedgroup.com/" rel="nofollow" target="_blank">https://www.venturemedgroup.com/</a> KDOQI Clinical Practice Guideline for Vascular Access, 2019 Update:<a href="https://www.ajkd.org/article/S0272-6386(19)31137-0/fulltext" rel="nofollow" target="_blank">https://www.ajkd.org/article/S0272-6386(19)31137-0/fulltext</a> Fahrtash, F., Kairaitis, L., Gruenewald, S., Spicer, T., Sidrak, H., Fletcher, J., Allen, R., &amp; Swinnen, J. (2011). Defining a significant stenosis in an autologous radio-cephalic arteriovenous fistula for hemodialysis. Seminars in dialysis, 24(2), 231–238. Haskal, Z. J., et al. (2010). "Stent graft versus balloon angioplasty for failing dialysis-access grafts." New England Journal of Medicine 362(6): 494-503. Bard Peripheral Vascular. Covera vascular covered stent instructions for use. Rev.4 / 08-18.<a href="http://www.bardpv.com/eifu/uploads/BAWB05872R4-Covera-Vascular-Covered-Stent-IFU.pdf" rel="nofollow" target="_blank">http://www.bardpv.com/eifu/uploads/BAWB05872R4-Covera-Vascular-Covered-Stent-IFU.pdf</a>. The Fight Doctors:<a href="https://thefightdoctors.com/about/" rel="nofollow" target="_blank">https://thefightdoctors.com/about/</a> Find this episode on <a href="http://BackTable.com" rel="nofollow" target="_blank">BackTable.com</a> for all resources mentioned in this podcast, including references to journal articles.

Ep. 292 Dialysis Interventions with Drug-Coated Balloons, Covered Stents and More with Dr. Ari Kramer

We talk with Vascular Access Surgeon Ari Kramer about AV Fistula and Graft Maintenance in dialysis patients from creation to long-term care, as well as tips and tricks for treating stenoses.---SHOW NOTESIn this episode, vascular access surgeon Dr. Ari Kramer and our host Dr. Chris Beck discuss the creation, management, and salvage of AV fistulas and grafts.Dr. Kramer describes the referral patterns that lead dialysis patients to his practice, citing the need to coordinate dialysis care around a common surgical practice. He works closely with nephrologists and dialysis centers to ensure quality of care and streamlined patient management. During an initial workup, Dr. Kramer includes a physical assessment and an echocardiogram to establish a baseline.The doctors discuss the pros and cons of using AV fistulas versus grafts. While AV fistulas are autogenic and carry a lower risk of infection, there is a risk that these may not mature. On the other hand, AV grafts are fully matured but they carry a higher risk of infection and require a higher intervention rate. Dr. Kramer emphasizes the importance of understanding a patient’s cardiac performance and history before selecting a method of AV access. He also schedules periodic follow-up appointments to ensure that the access site reaches maturity, which is evaluated by the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines.Dr. Kramer walks us through devices and procedures for angioplasty, stent placement, and drug coated balloon placement. Finally, he addresses strategies for managing re-stenosis and considerations for patient preferences regarding surgical revision.---RESOURCESKidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guideline for Vascular Access: 2019 Update: https://www.ajkd.org/article/S0272-6386(19)31137-0/fulltext#secsectitle0720American Society of Diagnostic and Interventional Nephrology (ASDIN): https://www.asdin.org/page/A2Kidney Academy (use code “backtable21” for free access): https://www.kidneyacademy.com/

We talk with Vascular Access Surgeon Ari Kramer about AV Fistula and Graft Maintenance in dialysis patients from creation to long-term care, as well as tips and tricks for treating stenoses. --- SHOW NOTES In this episode, vascular access surgeon Dr. Ari Kramer and our host Dr. Chris Beck discuss the creation, management, and salvage of AV fistulas and grafts. Dr. Kramer describes the referral patterns that lead dialysis patients to his practice, citing the need to coordinate dialysis care around a common surgical practice. He works closely with nephrologists and dialysis centers to ensure quality of care and streamlined patient management. During an initial workup, Dr. Kramer includes a physical assessment and an echocardiogram to establish a baseline. The doctors discuss the pros and cons of using AV fistulas versus grafts. While AV fistulas are autogenic and carry a lower risk of infection, there is a risk that these may not mature. On the other hand, AV grafts are fully matured but they carry a higher risk of infection and require a higher intervention rate. Dr. Kramer emphasizes the importance of understanding a patient’s cardiac performance and history before selecting a method of AV access. He also schedules periodic follow-up appointments to ensure that the access site reaches maturity, which is evaluated by the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines. Dr. Kramer walks us through devices and procedures for angioplasty, stent placement, and drug coated balloon placement. Finally, he addresses strategies for managing re-stenosis and considerations for patient preferences regarding surgical revision. --- RESOURCES Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guideline for Vascular Access: 2019 Update: <a href="https://www.ajkd.org/article/S0272-6386(19)31137-0/fulltext#secsectitle0720" rel="nofollow" target="_blank">https://www.ajkd.org/article/S0272-6386(19)31137-0/fulltext#secsectitle0720</a> American Society of Diagnostic and Interventional Nephrology (ASDIN): <a href="https://www.asdin.org/page/A2" rel="nofollow" target="_blank">https://www.asdin.org/page/A2</a> Kidney Academy (use code “backtable21” for free access): <a href="https://www.kidneyacademy.com/" rel="nofollow" target="_blank">https://www.kidneyacademy.com/</a>

Ep. 139 AV Fistula and Graft Maintenance with Dr. Ari Kramer