Dialysis Access Management
If you have kidney disease and need dialysis, we'll need to create access to your bloodstream. For dialysis to work, blood has to leave your body, move to the dialysis machine (artificial kidney), and then come back to your body. We make this possible with a vascular access.
There are several types of vascular access, including arteriovenous (AV) fistulas and grafts. Grafts are made out of manmade materials. Fistulas come from your own vein and artery. We can also place catheters and peritoneal dialysis catheters when necessary. In general, fistulas have fewer complications than other types of vascular access.
Our team of vascular surgeons and dedicated Dialysis Access Coordinator begin collaborating with our patient's nephrologist and dialysis center as soon as the eventual need to begin hemodialysis is realized.
Each patient will have a vein mapping study performed by one of our Registered Vascular Technologists at Columbia Surgical Associates. In addition to a physical exam and consultation with a vascular surgeon, this study will help to determine the best location for the access placement.
The placement of a fistula or catheter can be performed in an outpatient surgery center on some occasions, but it is usually performed in the hospital setting. A dialysis access should be placed weeks or months before the first hemodialysis treatment if possible, because the access needs time to mature before it can be used.
There are a few different options for dialysis access:
- Arteriovenous fistula
- Arteriovenous graft or a central venous catheter.
The major advantages of an AV fistula are that it provides good blood flow needed for dialysis, it is the longest lasting access option, and is less likely to get infected or become clotted. For these reasons, Columbia Surgical Associates is an active supporter of the "Fistula First" initiative.
An AV fistula usually requires two to three months to mature and develop before it can be used for hemodialysis. If an AV fistula fails to mature, then a surgeon will need to make a new fistula or proceed to placing an AV graft.
A catheter is usually placed if a patient does not have time to place a fistula or graft before needing to start dialysis because the kidney disease has progressed quickly or an existing access malfunctions.
A perm catheter is not ideal for long-term use. Patients can develop blood clots, infection and scarred veins which cause the veins to narrow.
AV Fistula
An AV fistula is created by attaching a vein to an artery. The vascular surgeon usually places the fistula in the forearm or upper arm. An AV fistula creates extra pressure and extra blood flow in the vein, which makes it grow large and strong. The larger vein makes it easier to perform dialysis treatments and withstand repeated needle sticks.
AV Graft
An AV graft is a looped or straight plastic tube that connects an artery to a vein. A patient can usually use a graft two to three weeks after surgery. An AV graft is more likely to get infected or have problems with clotting because it is not your own natural tissue. With good long-term care of the graft, it can provide a good means to receive dialysis and last for several years.
Central Venous Catheter (Perm Cath)
A catheter is inserted in a vein in the neck, chest, or leg near the groin. This option is used only for short term dialysis access. There are two tubes that exit the body, one that carries blood to the dialyzer and one that carries blood back to the patient. To prevent the chance of infection, it is not possible to shower with this type of access.
The partnership between all of the teams coordinating dialysis treatment for our patients continues on long after the access placement. In fact, studies have shown that a preventive maintenance or surveillance program can dramatically lengthen the life of an AV fistula or AV graft and improve the quality of dialysis treatments over time. Our dialysis access management program has been developed around routine surveillance.
Once your access has been placed, we will begin to see you regularly at CSA Surgical Center for routine surveillance. The patients in our program become like family to us and we truly look forward to seeing you and making this an easy and comfortable experience!
Procedure
A fistulogram may be performed with a local anesthetic or numbing medicine. There is typically no anesthesia or sedation, which allows our patients to have no dietary restrictions on the day of their procedure and to drive themselves to and from appointments. Normal medications can be continued unless instructed otherwise.
The procedure involves a physical examination of the fistula and then placement of a needle or small sheath into the fistula. Contrast dye is then injected into the fistula and radiography equipment is used to obtain a series of images from the bottom of the fistula to the chest all through the same access in the fistula. Patients may feel a warm sensation in their hand and upper arm when the dye is injected.
Patients have the option of watching the images on the screen during the exam. These images help the surgeon to determine if there are any areas of narrowing or concern in the vein. There is usually very little to no discomfort during a fistulogram.
If an area requires treatment to improve the function of the access, a ballooning or angioplasty procedure can be performed at the same time. The angioplasty procedure will be performed by placing a sheath into the vein. This sheath is similar to the one used to perform the fistulogram. Although many patients do not experience discomfort during an angioplasty, some patients can experience mild to moderate discomfort just while the balloon is re-opening the narrowed area. This usually lasts less than 1 minute. A stitch may be placed at the end of the procedure and will be covered with a band aid. Even with an intervention, most patient appointments take between 30-45 minutes total from check-in to discharge.
Indications
Patients in our dialysis access management program will have routine fistulograms every 3 months, unless an area of concern has recently required treatment. In that case, we will see that patient back in 6 weeks to ensure that narrowing has not re-occurred. Once a patient has several normal fistulograms, we can begin to space out their future appointments.
We often see patients as a result of changes or issues that are detected by our partners at the dialysis centers. These changes can be communicated to our dedicated Dialysis Access Coordinator by the patient or the dialysis clinic. Some examples of concerns that might require prompt evaluation by one of our surgeons include:
- Difficulty with accessing the fistula at dialysis
- Arm swelling
- Prolonged bleeding after treatment
- High Venous pressures
- Low flow studies
These can all be signs that something has changed and could result in the fistula "clotting off" if not promptly addressed. When a fistula clots, it can require surgical intervention at the hospital in an attempt to save the fistula and can also result in permanent loss of the access requiring placement of a perm cath and a new fistula in a different location. This is a situation we all want to avoid and routine fistula maintenance has been proven to do just that.
We will discuss any significant findings with your dialysis clinic and nephrologist on your behalf. You may also receive pictures to take back to the team at the dialysis clinic.
Recovery
You may have a stitch where the surgeon accessed the fistula. This stitch will dissolve on its own over time or can be removed at the dialysis clinic in 1 week. If dialysis does not remove stitches and you would like the stitch removed, you can call our Dialysis Access Coordinator for an appointment around your schedule.
There are no restrictions after this procedure and it has no impact on a patient returning to dialysis as scheduled. We also work to coordinate appointments around dialysis schedules to minimize any interruptions in regularly scheduled dialysis treatment.
For More Information
To listen to our board certified surgeons answer your most frequently asked questions, please visit our FAQ page.
To Make an Appointment
Your initial consultation gives you the opportunity to meet our team, learn more about our services and find out which treatment options will best meet your needs.
To schedule a prompt appointment with one of our board-certified vascular surgeons, please call our dedicated Dialysis Access Coordinator at Columbia Surgical Associates: 573-777-3303
Dr. Salinas
Dr. Adams
Dr. Sanford