Vascular Surgery

Hemodialysis Access

Dr. Steven Curtiss, Scott Rosen and Alissa Brotman O’Neill, offer a wide array of Vascular Surgical services.  Including, hemodialysis access, aortic and arterial aneurysm repair, carotid artery, varicose vein treatment.

Many patients may require hemodialysis to remove fluid and toxins from the body which accumulate when the kidneys are not functioning normally. In order for this to be performed we must be able to deliver a continuous flow of blood from the patient to the dialysis machine and back to the patient during a dialysis treatment. In general, patients undergo hemodialysis three times per week. The most efficient and safest way of providing blood flow is by creating an access in the arm through a surgical procedure. The two major types of these are the arteriovenous fistula (AV fistula) and the AV graft.

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Types of Dialysis Access
An AV fistula is a communication made by sewing together a natural vein to an artery in the arm. This is most often done through a small incision at the wrist or the elbow. We hope that over a period of eight weeks, or so, the vein will become large enough (or mature) so that let can be cannulated with needles attached to the dialysis machine. The natural AV fistula has the best results of any type of dialysis access. Unfortunately, many patients close to needing dialysis have very poor veins which have been damaged from IV and blood draws making the creation of a fistula difficult in certain patients. Because of this and the time needed for maturation it is important that patients get evaluated for a dialysis access early and avoid blood draws or IV’s in their non-dominant arm as soon as they are found to have significant kidney problems. If a patient’s veins are too small for creation of an AV fistula, an AV graft is constructed, which is an artificial tube placed under the skin in the forearm or upper arm connecting an artery and vein. After about three weeks the graft can be used for dialysis. Grafts work well for dialysis in many patients but don’t last as long as AV fistulas and are more prone to infection. In general we try to create an AV fistula whenever possible and use a graft as a second choice. In certain patients the need for dialysis is so urgent that there is no time to wait for maturation of either a graft or a fistula, and a special tube called a catheter needs to be placed in one of the large veins in the neck. Catheters are much more prone to problems such as infection than either a fistula or a graft and are usually considered temporary access until an arm access or even a leg access can be developed. You may have heard of them referred to by brand names such as Permacath, Tessio or Shiley.

The Procedure

Most dialysis access procedures can be performed with local anesthesia and sedation or “twilight anesthesia”. As with any procedure there are certain complications and problems which can occur. It is important for the patient their families to understand the risk and benefits as well as the alternatives to any proposed procedure. If you have any questions or feel things have not been explained adequately, it is very important that you notify your surgeon and they will be happy to review things again and answer any questions you may have. First of all, any access which is placed may fail to work. In some populations up to 40% of natural fistulas may not develop. Often times however these fistulas can be salvaged so they can be used. Any type of access can become infected but this is more likely with catheters and grafts than fistu-las. Sometimes these can be severe and even life threatening. Although these are, in general, safe procedures they can be associated with bleeding swelling or clotting. Grafts and fistulas can result in too much blood being taken away from the hand, or a “steal” syndrome, and rarely nerve injury. These conditions can lead to pain, numbness and even functional impairment and tissue loss in the hand or fingers. When catheters are inserted in the large veins in the neck or chest this is done with a needle or small incision but can be associated with rarely with a collapse of a lung, significant bleeding or embolus. In severe cases they can even be fatal. In general dialysis access is safe and the risks are in general less than forgoing dialysis if it is truly needed. Catheters are considered to have more complications and problems in the long-term than either grafts or fistulas.

A Successful Outcome
You can maximize your chances of having a successful dialysis access by following a few simple guidelines. First make sure your surgeon is experienced in dialysis access and has explained the procedure and answered all your questions to your satisfaction. You should avoid blood draws and IVs in one arm as soon as you are told that you have kidney problems. This is generally the non-dominant arm or the arm opposite the side of a pacemaker or defibrillator if you should have one. The better veins the surgeon has to work with the better chance you will have a successful procedure. The sooner you have an AV fistula placed the more time it will have to develop or mature prior to actually being needed. This may avoid the need for a temporary catheter. Make sure your surgeon knows if you are on blood thinners, have clotting or bleeding problems or have a pacemaker, implantable defibrillator or any allergies prior to the surgery. You will generally be scheduled for an ultrasound prior to the surgery to test the quality of the veins available. The night before the surgery you should wash the arm with a gentle antibacterial soap. In general you will see your surgeon anywhere from one to three weeks after the procedure. If your surgeon is satisfied at the first post op visit you should begin squeezing a ball with the hand of the fistula arm to help it develop quicker. Absolutely no blood draws, IVs or blood pressures should be done in this arm. Your surgeon and nephrologist will decide when the access is ready to use. You should report any bleeding pain, drainage or swelling to your surgeon. Ask your surgeon or nephrologist to show you how to examine your access with your hand and a stethoscope and let your Doctor know immediately if there is a change. If you are not clear about any aspect of your procedure contact your surgeon.
Vascular Surgery

Dialysis Access

  1. Fistula and Graft
  2. Catheter
  3. Revision and Repair of non-functioning access

Peripheral Vascular Disease

  1. Peripheral Artery Disease
    • Carotid Stenosis
    • Lower Extremity
  2. Peripheral Venous Disease
    • Venous stasis
    • DVT

Mediport & PICC Lines

  • Access for chemotherapy and medication infusion

Vein Treatment