Dialysis Access Maintenance
Dialysis programs are often used to aid patients suffering from kidney failure. To create optimal care for these patients, they need procedures performed on their veins, arteries and accesses. Our physicians specialize in the following procedures:
- Dialysis access procedures – fistula maturation, fistulograms, thrombectomy, and percutaneous ligation (the Miller Procedure)
- Central line placements, ports (arm and chest), Hickman and Groshong catheters, dialysis/pheresis catheters
- Venograms, venous angioplasty/stents
- Peritoneal dialysis catheters
Choose from the following to learn more:
- Fistula Maturation
- Graft Re-canalization
- Steal Syndrome Treatments
- Angioplasty & Stent Placement
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. Preoperative venous (as well as arterial) imaging can reduce the number of non-maturing fistulas. Careful postoperative evaluation is also essential. A fistula should be examined at approximately four weeks following creation.
Ultrasounds can determine vein diameter, areas of stenosis, significant accessory veins, and blood flow. Following a duplex ultrasound, the next step for a non-matured fistula is a contrast fistulogram.
Intervention usually consists of balloon angioplasty of all significant stenosis, as well as obliteration of significant accessory venous branches.
A dialysis fistulogram involves the placement of one or more plastic tube(s) (catheters) into your dialysis graft/fistula. Some numbing medicine will be injected in the skin over the graft/fistula before the catheter is inserted. Intravenous medications may also be given to you to make you more comfortable and relaxed. This is known as moderate sedation. Once the catheter has been placed into the graft/fistula, it will be advanced through the blood vessels.
During this time, X-ray contrast material (X-ray dye) will be injected through the catheter and X-ray pictures are taken. You may be asked to hold your breath for several seconds as these pictures are taken. During the injection of X-ray contrast material, you may experience a warm feeling or a strange taste in your mouth. Both of these sensations are temporary and will go away soon.
Depending on the results of the fistulogram, an angioplasty, stent placement, or thrombolytic therapy may be performed. At the completion of the fistulogram, the catheter(s) will be removed and pressure will be applied to the insertion site(s) until the bleeding has stopped.
The most common problem experienced with dialysis access devices is clotting, or thrombosis. Blood clots can form in temporary access catheters, fistulas, and grafts. Clotting can decrease or stop blood flow and make dialysis impossible.
In some cases it is possible to use thrombolytic agents to dissolve the clot. In a thrombectomy, clotted temporary catheters are injected with special thrombolytic agents or are replaced.
Clotting is a more common problem for grafts than for fistulas. (Blood is stimulated to clot by artificial substances; blood vessel walls contain substances that help to prevent clotting.) 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 doctor or your surgeon.
Graft re-canalization is the utilization of angioplasty, lysis, and/or thrombectomy to reestablish or maintain the access for hemodialysis.
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 Syndrome 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
(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.
Angioplasty & Stent Placement
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-tipped catheter (a long, thin plastic tube) into an artery or vein and advance it to where the vessel is narrow or blocked. The balloon is then inflated to open the vessel, deflated, and removed.
In vascular stenting, which may be performed with angioplasty, a small wire mesh tube called 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) and covered stents (also commonly called stent grafts).
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:
- Renal Vascular Hypertension
High blood pressure caused by a narrowing of the kidney arteries. Angioplasty with stenting is a commonly used method to open one or both of the arteries that supply blood to the kidneys. Treating renal arterial narrowing is also performed in some patients to protect or improve the renal function.
- Narrowing in Dialysis Fistula or Grafts:
A very common condition involving narrowing of 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. The procedure is often done on an outpatient basis
The equipment typically used for this examination consists of a radiographic table, an X-ray tube, and a television-like monitor that is located in the examining room or in a nearby room. A guide wire is a thin wire used to guide the placement of the diagnostic catheter, angioplasty balloon catheter, and the vascular stent. A sheath is a vascular tube placed into the access artery, such as the femoral artery in the groin that allows catheter exchanges easily during these complex procedures. A balloon catheter is a long, thin plastic tube with a tiny balloon at its tip. A stent is a small, wire mesh tube. Balloons and stents come in varying sizes to match the size of the diseased artery. Stents are specially designed mesh, metal tubes 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.