End Stage renal Disease (ESRD) occurs when the kidneys are no longer able to function. ESRD patients need dialysis, an artificial process for removing waste products and excess fluids from the body that are normally eliminated by the kidneys. Kidney failure is the most common cause for dialysis. Dialysis requires that the patient have a well-functioning access. We specialize in the following dialysis access management procedures.
- Dialysis Access Procedures – Thrombectomy, Fistulograms, Fistula Salvage, Angioplasty, Stenting, Balloon Assisted Manturation, the MILLER Banding Procedure and Superficialization of the AVF
- Central Line Placements (Dialysis Catheters, and Peritoneal Dialysis Catheters, Ports, PICCS)
- Venograms, Venous Angioplasty/Stenting
Dialysis Access Procedures
Angioplasty and Stenting
Angioplasty and vascular stenting are minimally invasive procedures performed to improve blood flow in the body’s arteries and veins. In the angioplasty procedure, imaging techniques are used to guide a balloon catheter into an artery or vein and advance it to where the vessel is narrow or blocked. The balloon is inflated to open the vessel, then deflated and removed. A balloon catheter is a long, thin plastic tube with a tiny balloonmounted on it. A stent is a small, wire mesh tube. Balloons and stents come in varying sizes to match the size of the diseased artery. In vascular stenting a stent, is permanently placed in the newly opened artery or vein to help it remain open. There are two types of stents: bare stents (wire mesh with no covering) and covered stents (also commonly called stent grafts). Stents are specially scaffolds that are inserted into the body in a collapsed state on a catheter and then expanded inside the vessel to prop the walls open. In some cases the stent may have a synthetic fabric covering. Angioplasty and angioplasty with vascular stenting are commonly used to treat conditions that involve a narrowing or blockage of arteries or veins throughout the body, including:
Narrowing in Dialysis Fistula or Grafts
It is very common to see narrowing involving the dialysis fistula or graft. When there is decreased flow in the graft or fistula that is not adequate for dialysis, angioplasty is generally the first line of treatment. Stenting or stent-grafting may also be needed in some cases. In these procedures, X-ray imaging equipment, a balloon catheter, sheath, stent, and guide wire are used. This procedure is often performed on an outpatient basis.
Declot Procedure for Dialysis Patients: Thrombectomy
The most common problem experienced with dialysis access is clotting, or thrombosis. Blood clots can form in temporary access catheters, fistulas, or grafts. Clotting can decrease or stop blood flow and make dialysis impossible. Clotting is more in grafts than fistulas. It is usually possible to tell by examining a fistula or graft if there is good flow through it. Good flow is turbulent and often produces a rhythmic buzz or thrill. The access should be checked frequently. If it appears that the device has stopped working, notify your dialysis caregiver. Removing the clot is known as a thrombectomy. In some cases it is possible to use thrombolytic agents to dissolve the clot (thrombolysis).
Prevention and Surveillance
In order to decrease the incidence of thrombosis and other access-related complications, the Kidney Dialysis Outcomes Quality Initiative (KDOQI) guidelines for vascular access surveillance were developed. A routine vascular access surveillance program, combined with early diagnosis and repair of stenoses, can decrease the incidence of vascular access thrombosis and prolong graft longevity. Several studies have demonstrated an increase in graft survival when elective treatment, using either endovascular or surgical techniques, is performed prior to graft thrombosis. Other advantages of good surveillance include:
- Reduced morbidity
- Efficient, continuous, uninterrupted hemodialysis
- Less need for temporary hemodialysis catheters
- Fewer hospital days for access-related problems
- Increased graft longevity
- Reduced rate of graft replacement
- Improved quality of life
Defining and Detecting Maturation
Fistula maturation requires adequate arterial inflow, adequate venous outflow, and the ability of the vein to dilate to increase blood flow enough to allow repetitive cannulation for dialysis. Pre-operative venous, as well as arterial, imaging can reduce the number of non-maturing fistulas. Careful post-operative evaluation is also essential. A fistula should be examined at approximately four weeks following creation. Ultrasound can determine vein diameter, areas of stenosis, significant accessory veins, and blood flow. Following duplex ultrasound, the next step for a non-matured fistula is a contrast fistulogram. Intervention usually consists of balloon angioplasty of all significant stenoses as well as obliteration of significant accessory venous branches.
Dialysis-associated steal syndrome (DASS) is defined as a clinical condition caused by arterial insufficiency distal to the dialysis access owing to diversion of blood into the fistula or graft. It is usually asymptomatic, not requiring treatment. Symptomatic steal occurs in patients who are unable to develop collateral or direct flow to offset steal. Diagnosis of DASS requires three criteria to be fulfilled: (1) symptoms highly suggestive of DASS; (2) absent forearm pulses; and (3) radiographic criteria. Treatment options include sacrifice of the access, flow reduction procedure (banding), percutaneous transluminal angioplasty (PTA) of arterial stenosis, embolization, and various revascularization surgeries.