Problems We Address
High arterial or venous pressures
Clotted graft or fistula
Pain in the access or arm
Steal syndrome (coldness, pain, numbness in the hand)
Catheter dysfunction and infection
Vessel mapping (for surgical planning)
Claudication (pain at rest or during exercise) symptoms in the legs
Non- healing wounds in the lower extremities
Procedures That We Do
A fistulagram is an X-ray study in which a small needle (much smaller than a dialysis needle) is inserted into the fistula or graft and contrast is injected into the access to better visualize the vessels. This allows your doctor to see if there are any blockages or abnormalities that need to be corrected
Narrowing or blockages in your access can lead to multiple problems including high pressures during dialysis, cannulation problems, poor clearances, prolonged bleeding, discomfort, and even complete clotting. If a significant narrowing is seen during a fistulagram, a balloon is placed across the area, and it is expanded and stretched from the inside. The ballon is then withdrawn, and repeat imaging is performed to confirm that the area is no longer narrow.
Occasionally, the vessel or graft may remain narrow despite aggressive balloon angioplasty of the area. Since the balloon may not correct the problem, a stent (expanding metal tube) is needed to hold the area open and treat the underlying stenosis. The stent is deployed through a small sheath in the access and expanded from the inside. Just like a balloon angioplasty, no incision is needed. A stent, however, is permanent and will remain in the access. Stents come in a variety of sizes and materials, and your doctor will choose the best type for the location and problem that is present. Stents can be very helpful in prolonging the life of an access.
Multiple factors contribute to an access clotting, including narrowing in the vessels, infiltration, accessory veins, low blood pressure, excessive external pressure, “thick blood”, sleeping on the arm, and other issues that increase inflammation. A thrombectomy is a procedure that removes the old clots from the access and re-establishes flow. This procedure uses devices such as balloons and clot-dissolving medications to accomplish this task.
New fistulas need time to develop into vessels that are large enough and have enough flow to be usable. Frequently, certain issues such as narrowing of the vessels or extra “accessory” veins prevent this maturation. During fistula maturation procedures, both of these issues can be corrected using balloon angioplasty or coil embolization techniques. Fistula maturation can usually start 6-8 weeks after initial placement of the fistula, and it is usually accomplished in 2-3 visits spaced a couple of weeks apart.
Patients may develop complete blockages in the central veins that drain blood back to the heart. This can happen for many reasons, including prior use of central catheters. Patients can have symptoms such as swelling of the face, neck, or arm, as well as repeated problems with dialysis access function. This procedure allows for re-cannulation of the central blockage with preservation of the dialysis access. Minimally invasive techniques are used with wires placed into the fistula as well as through the groin to allow the best approach for repair.
Aneurysms are balloon-like enlargements in the vessel or graft that occur from repeated puncture of the access. Sometimes these aneurysms can be at risk for rupture, and your doctor and dialysis unit will monitor how urgent a repair may be needed. Some repairs require surgical intervention, but some can be repaired using the same minimally invasive techniques above. Stents with a graft material covering are available and allow correction of a potentially dangerous aneurysm in a matter of minutes. Your doctor will discuss if this is a good option, depending on the size and location of the aneurysm.
Dialysis patients are at particular risk for atherosclerosis of the arteries that supply the legs. Symptoms can include pain in the legs or feet, discomfort while walking, discoloration, and poorly healing wounds. Without intervention, these patients can be at risk for infection and amputations. Using similar minimally invasive techniques as described above, blood flow is re-established in the legs. Recovery time is very short, and open bypass surgery can often be avoided.
Peritoneal dialysis is a good dialysis modality that gives patients the ability to do dialysis at home and have greater autonomy in their care. If you are referred for PD catheter placement, you will have an initial office visit with the doctor to discuss the procedure and be fitted for the catheter. On the day of the procedure, both ultrasound and Xray will be used to place the catheter into the abdomen. Intravenous sedation and local lidocaine will be used, and recovery time is generally very short due to the minimally invasive approach.
Tunneled catheters are used as a bridge for patients until a functioning fistula or graft is available. This procedure involves placement of a catheter usually into the internal jugular vein using a combination of ultrasound and Xray imaging. The catheter is then tunneled under the skin and over the clavicle, exiting through the skin in the upper portion of the chest. The procedure uses both IV sedation as well as local lidocaine. Multiple different sizes and types of catheters are available, and your doctor will pick the best type to fit each individual need.
It is important for your surgeon to have a roadmap of your current vessels prior to surgery for a new fistula or graft. This map will help the surgeon determine which vessels to use and what type of access will be needed. The procedure consists of a small IV in the hand or hands followed by contrast injection into the veins. Xray imaging will be performed of the arms and chest.