Dialysis and Vascular Access

We are pleased to be able to provide you with complete vascular access service. As vascular surgeons, we will work with you and your nephrologist every step of the way, from planning where and what type of dialysis access you should have, to maintaining your access and fixing any problems that may come up. We are always available to help care for you and your dialysis access. Our goal is to make sure you have an excellent functioning access for as long as you may need it.

Hemodialysis
The Centers for Medicare and Medicaid Services (CMS) has set a national goal of 66% arteriovenous fistula (AVF) use rate. We are proud to say that in our area, we have been able to achieve >70% prevalence of fistulas since 2009.

Both arteriovenous fistulas and grafts are permanent types of access that can last for several years if they are cared for properly. However, all dialysis access requires regular monitoring and maintenance. This process starts with you, the patient, before surgery is even done! You must make sure that no one ever checks your blood pressure, puts an IV, or takes blood from the arm that you and your surgeon have selected to be the active access arm. Once your access has been placed, you should avoid wearing any tight bands or cuffs across the arm. Once the access is in regular use, the dialysis nurses will check the flow and function of the access - ask them to keep you informed about how it is working and what your flows are. Most fistulas need maintenance procedures (like tuning up your car) once or twice a year; grafts may need more frequent tune-ups, such as three or four times a year. These procedures, called fistulograms, are most often minimally invasive and no more painful than when you are hooked up to the dialysis machine. Occasionally, your fistula or graft may need to have a surgical revision.

After your access has been used for awhile, there are certain signs and symptoms that you should watch for that can suggest a developing problem with your access.

These include:

• Decreased flows, or the need for longer dialysis times
• Prolonged bleeding after being taken off the dialysis machine
• Skin ulcers or wounds where the dialysis needles have been placed
• Redness or pain around your access
• New swelling of your entire access arm
• Growing bulges where the dialysis needles have been placed

Peritoneal dialysis
Clinical applications of peritoneal dialysis were first attempted in the 1920-30's. Catheter design optimization followed in the 1960's. Peritoneal dialysis is of two types: continuous ambulatory peritoneal dialysis (CAPD), or continuous cycling peritoneal dialysis (CCPD, or automated peritoneal dialysis, APD). CAPD is "machine-free" and is based on gravity exchanges done 4-5 times per day. CCPD relies on a portable, automated machine that performs the exchanges overnight.

Peritoneal dialysis is useful particularly for pediatric patients, patients with volume-sensitive cardiac disease, difficult blood vessels for access (severe peripheral atherosclerosis, obesity, scarred veins, hypercoagulability) and those who need more daily autonomy and freedom. The primary contraindications are extensive intra-abdominal adhesions or fibrosis, irreparable abdominal hernias, inflammatory bowel disease, frequent diverticulitis, abdominal malignancy, and possibly chronic constipation. The main risks long-term are of infection and peritonitis, which may require removal of the catheter and conversion to hemodialysis. The peritoneal catheter is placed in the operating room via a small incision in your abdomen and usually can be used within 2 weeks.

Although hemodialysis is the most common modality of choice in the US, peritoneal dialysis is more prevalent in many other countries of the world. For many patients, peritoneal dialysis provides similar survival with a more flexible quality of life, fewer dietary and fluid restrictions, and no needle sticks. Education is critical in deciding whether or not this is the proper treatment for you, and this is something that you should discuss with your nephrologist.