Taking care of the dialysis fistulas for renal failure patients

Taking care of the dialysis fistulas for renal failure patients

#dialysis #vascularsurgeonpune #fistula

Dr. Nupur Sarkar

Vascular and Endovascular surgeon

MBBS (CMC Vellore), MS (Gen Surg – CMC Vellore)

MCh (Vascular Surgery – MMC Chennai)

FIVS (Fellowship in vascular and endovascular surgery, Austria)

          Patients who have been diagnosed with chronic renal failure (CRF) are usually started on renal replacement therapy (RRT) while evaluation towards a possible renal transplantation (RTx) is started. However, in a developing country like India, due to shortage of eligible voluntary donors / cadaver donors and restricted financial resources, more often than not patients need to be on chronic haemodialysis / peritoneal dialysis.

          

            A nephrologist is the best person to judge which modality of dialysis is best suited for a particular patient keeping in mind his/her age, comorbidities, reason for kidney failure and financial condition. For many patients, haemodialysis is chosen as the most cost-effective option. For haemodialysis, a ready “access” to the blood vessel is required which should be able to be used for months and even years. Often patients have a long catheter inserted into their neck or chest (dialysis catheters) which can be connected to the dialysis machine. This is one of the easiest and fastest ways to start a patient on dialysis. However, it may be uncomfortable for some patients and also puts the patient at risk for infections. Moreover, prolonged use of these catheters can cause some narrowing of the blood vessel which can make it difficult later to create a successful “fistula” in the upper limb on that side.

          

           One of the most cost-effective options for access for haemodialysis is “fistula”. The correct medical term for this is “Autogenous Arteriovenous Fistula”. However in common language it is often referred to as “fistula” or “shunt” for dialysis. Fistula establishes a connection between vein and artery and is usually done in the forearm or at the level of the wrist by a surgeon in an operation room usually under local anesthesia.  This procedure can take about 45 minutes. Sutures can be removed after a week. It does not create any problems with movements of the wrist but still the non-dominant hand is given preference to avoid any inconvenience to the patient while performing daily activities. Even children with renal failure with weight as low as 15kg can be offered a “fistula” for dialysis. The fistula takes atleast 6 weeks to “mature” – to become ready for use for dialysis. It may take upto 2-3 months in children to “mature”. Early cannulation or use for dialysis of these fistulas should be avoided as it can cause problems and often the fistula then fails. Despite best measures, a small percentage5- 10% of these fistulas never mature enough to be used for successful dialysis and for these patients, a second surgery may be required. In some patients with vasculitis / SLE causing renal failure, often the fistulas fail multiple times. However, a well-created and functioning fistula especially at the wrist level can be kept active and useful for as many as 10 years or more, thus significantly decreasing costs and economic burden to the patients. That is why these natural fistulas should be offered to each and every patient with renal failure.

          

           Sometimes, some patients do not have any suitable veins for a successful fistula surgery or multiple attempts to create a fistula have failed. These patients should be offered a synthetic “graft” or “shunt”. This is placed surgically in the forearm, arm, thigh or chest wall. The currently available grafts can be used for dialysis as early as 24-36 hours after surgery.  So it is also useful in patients who need to start dialysis early and cannot wait for 6 weeks for a natural fistula to mature. However, these “grafts” do have their limitations – they often do not work longer than 6 months, they may require multiple procedures to keep it functional, they are expensive and they are at risk of infections. Therefore, they are not advised as first choice to patients. The last option is “permanent tunneled catheters” when all other options at fistulas/grafts have been exhausted. These again have the limitations of failure and infection.

Precautions to be followed by patients diagnosed with kidney disease or renal failure:

1.      1. Avoid use of the vein seen on the thumb side of the hand till the elbow (the cephalic vein) for giving blood for investigations or for IV cannula placement. Please inform the doctor/nurse that you have renal failure and that this vein needs to be preserved for a future fistula surgery.

2.    2.    If you need emergency dialysis, request for a catheter to be placed on the right side of the neck or chest or in the legs. Avoid the left side of the neck.

3.       3. Consult a specialist fistula surgeon early for advice regarding timing of fistula surgery. Earlier the better. In fact, medical literature has now proven that the best time to have this surgery is 3-6 months in advance before weekly dialysis becomes necessary. This requires careful co-ordination between the nephrologist, the fistula specialist surgeon and the patient.

Surgical specialties who can do fistula surgery:

1.      1.  Vascular surgeon – Worldwide, it has been accepted that the best results of fistula surgery are from vascular surgeons. They are the best qualified for any blood vessel surgery and can often offer multiple options especially for patients with failing/failed attempts at fistulas. However, in India, there are only around 250 qualified vascular surgeons. Therefore, often our colleagues from other surgical specialties have to help out with the patient burden.

2.      2.  Cardiothoracic surgeon with special interest in fistula surgery

3.     3.   Plastic surgeon with special interest in fistula surgery

4.      4.  Urosurgeon with special interest in fistula surgery

5.     5.   General surgeon with special interest in fistula surgery

Precautions for patients after a fistula surgery:

1.      1.  Avoid dehydration and sudden drop in blood pressure. Consult your nephrologist / surgeon on how much fluids can be taken safely per day. Also please adjust your medicines for blood pressure in consultation with your doctor so that there is no sudden drop in blood pressure.

2.       2.  Avoid pressure on the fistula site.

3.       3.While sleeping, do not place the fistula hand under your head or pillow.

4.      4.  Keep your fistula hand elevated over a pillow while sleeping.

5.      5.  Buy a rubber ball and keep exercising your fistula hand.

6.       6. If you feel the sound “machinery thrill” of the fistula has decreased or stopped, consult your surgeon early. Most of the times, these fistulas can be saved if you come for treatment early.

7.      7.  Make sure that blood pressure and blood tests are not taken on the fistula arm.

8.      8.  Make sure that IV fluids or drips are not started on the fistula arm.

 Figure 1 Courtesy www.nephroplus.com. Figure shows a “natural fistula” or “autogenous fistula”.

 Figure 2 Courtesy www.medindianet.com. Figure shows a fistula being used for dialysis.

Figure 3 Courtesy www.riversideonline.com. Figure shows a “synthetic fistula” or “graft”.

Diseases and conditions managed by a VASCULAR SURGEON.

Vascular and Endovascular Surgery

Dr. Nupur Sarkar

– MBBS (CMC Vellore), MS (General Surgery – CMC Vellore), MCh (Vascular Surgery – Madras Medical College Chennai), FIVS (Salzburg, Austria)

Vascular Surgery deals with diseases of all the blood vessels of the body, except for those inside the skull (Neurosurgery) and those of the heart (Cardiac Surgery). A vascular surgeon commonly deals with diseases of the arteries and veins. Today science and technology has advanced to a stage where there are treatment modalities available to prevent amputation and save many limbs. Just as angioplasty is possible to remove the blockages in the blood vessels of the heart and avoid bypass surgery, similarly angioplasty can be done for vessels going to the hands and legs and even to the brain. This is popularly known as “key-hole” surgery or minimally-invasive surgery or ENDOVASCULAR SURGERY. A vascular surgeon is equally trained in both open surgery and so-called “key hole” surgery (endovascular), so he/she is able to give a better perspective of which treatment modality or combination is best suited for a particular patient.

Lack of awareness in India regarding the availability of these treatment options means that many deserving patients are deprived the chances of early treatment and often lose their legs or lives due to the disease.

The specialty includes treatment for peripheral arterial occlusive disease (gangrene of the fingers or toes or non-healing ulcers on legs or hands), carotid diseases, aortic aneurysms / dissections, acute limb ischaemia, varicose vein surgery, treatment for DVT, arteriovenous malformations, thoracic outlet syndrome and creation of dialysis access fistulas for renal failure patients.

Because a large number of people with diabetes have blocked blood vessels leading to foot problems, vascular surgeons also deal with infection and gangrene problems of the foot in diabetics.

a) Limb salvage surgery (treatment for arterial occlusion of legs or hands)

Blocked arteries in the leg can be treated by either medications or surgery or both. The best method of treatment can be decided only after a thorough evaluation of the patient. Surgery commonly involves a bypass operation. Gangrene of the leg is a “leg attack” just like a block in the arteries of the heart causes a “heart attack”. If not treated properly, it can be both limb and life threatening.

Some people with blocked lower limb arteries can be treated with a newer method of treatment called endovascular surgery (minimally invasive). Here, the morbidity of open operations can be avoided by performing an angioplasty and stenting of the blocked blood vessel. Not everyone is a suitable candidate for endovascular surgery. The vascular surgeon is the best person to decide which form of surgery (open or endovascular) is best suited to a particular patient.

Vascular surgery is performed in order to improve the blood flow to the leg and stop further spread of gangrene. This can be limb saving as well as life saving.

b) Trauma

Many road traffic accidents result in complicated fractures of the legs or hands where the blood vessels get severely damaged. These blood vessels if not repaired as an emergency means that the blood supply to the leg is cut off and the patient may require an amputation. A specialized trauma team headed by a vascular surgeon and including an orthopaedic surgeon and plastic surgeon is required to operate these emergency cases and salvage the limbs.

c) Aortic surgery (for aortic occlusions, aortic aneurysms)

An aneurysm is a localised ballooning of the artery. It is deadly because the ballooned out blood vessel can burst and have fatal consequences. Aneurysms can involve any blood vessel of the body. Aneurysms of the aorta need special attention – both open and endovascular options are available and a vascular surgeon is best qualified to judge which option is the best for any particular patient.

d) Carotid endarterectomy and carotid stenting

Stroke is often caused by a blockage in the carotid arteries (which supply the brain). The risk of having a stroke can be decreased by either performing an open surgery or putting a stent in the carotid artery. Which treatment modality is best suited to a particular patient requires joint evaluation of the patient by a team led by a neurologist and including a vascular surgeon, neurointerventionalist and a neurosurgeon.

e) Varicose vein surgery – open, LASER, RFA and foam sclerotherapy

Bulged out veins under the skin are called varicose veins. They are unsightly and cause pain, nonhealing leg wounds as well as bleeding complications. Treating varicose veins on time prevents these complications.

Different methods of treatment exist for varicose veins. The treatments include stockings (special pressure-gradient compression), injection therapy (sclerotherapy), open surgery and laser / RFA surgery. Most often these patients need only 1 or 2 day hospital stay and can go back to their daily work the same week.

f) Creation of arteriovenous access for haemodialysis – fistulas and grafts

A vascular surgeon can help renal failure patients by providing a good dialysis fistula/graft. There are several options available in the forearm, arm or legs. Even children with weight as less as 15kg can have a successful fistula. There are options available to salvage failing fistulas and repair them, in certain cases.

g) Diabetic foot care

Diabetics are known to have a 4-5 times higher risk of blockage of leg blood vessels compared to normal people of the same age. This is why infections and gangrene are more common among the diabetics. Hence a vascular surgeon is involved in the care of diabetic foot diseases through dedicated DIABETIC FOOT CLINICS. Foot problems in diabetics are very common and can equal or exceed heart disease in morbidity and mortality. Lack of awareness of this fact is responsible for a lot of amputations and deaths among diabetics with foot problems in India.

h) Thoracic outlet syndrome treatment

Many patients with pain in the hands due to thoracic outlet syndrome are misdiagnosed and inappropriately treated. A vascular surgeon is able to provide treatment options for cervical rib and its complications.

i)Treatment of deep vein thrombosis (DVT)

Deep vein thrombosis means occlusion of the deep veins or the main veins of the legs or hands. Treatment options that we can offer include catheter-directed thrombolysis and IVC filters which can decrease the risk of life-threatening pulmonary embolism and disability later due to venous ulcers.

j) Miscellaneous

Other diseases that also come under the specialty of vascular and endovascular surgery include visceral artery occlusive diseases (mesenteric and renal), arteriovenous malformations, vasculitis (Takayasu’s arteritis), carotid body tumours, tumours of the legs or hands involving the blood vessels.

Symptoms
Pain during walking, inability to walk or sleep due to severe pain in leg or hands,

Gangrene of the fingers due to occlusion of arteries of the hand. (Acute limb ischaemia

CT angiogram showing an aortic aneurysm.

CT angiogram showing a large carotid body tumour encasing the carotid vessels.

A middle-aged female patient with deep vein thrombosis of the right leg.

Schematic diagram showing treatment of an aortic aneurysm by endovascular therapy (EVAR).

Gangrene of the left third toe in a young male smoker.

IVC filter used in patients with DVT to prevent life-threatening pulmonary embolism.

Non-healing ulcer in a young male smoker (Thromboangiitis obliterans / Buerger’s disease) – required femoro-distal bypass for limb salvage.

CT angiogram showing extensive occlusions of the arteries of both legs.

Varicose veins of the legs which requires treatment to prevent ulcers of the legs in the future.

A middle-aged male patient with a large venous ulcer of the left leg.

Understanding gangrene and its life-threatening impact

The dreaded word “gangrene” must be familiar to many patients suffering from diabetes and their caretakers. It essentially means the death of a part of the limb or organ. Diabetics are a very high risk group for this deadly condition. Nearly one in four diabetics has some degree of block in their arterial circulation and is at risk of developing gangrene. Most patients are unaware of the severity of the problem and tend to ignore it until it is too late. Gangrene is actually the culmination of a biological process which has been happening in the body probably for years. Unfortunately, removing the gangrenous part of the finger or toe is not the solution as it only worsens the situation. This is because the gangrene or death of the organ occurs due to a blockage in the arterial circulation of the organ or the limb as it prevents an adequate supply of oxygen and other nutrients from reaching this part of the body. The further the organ is from the heart, the higher is the risk to develop gangrene. That is why it is often seen in the tips of toes. The true solution is to somehow unblock the impediment to the circulation and restore the path for blood and oxygen to reach the organ.
Epidemiological research has now substantially established that India is one of the leading countries with regards to population suffering from diabetes. Smoking which is very prevalent in almost all societies of India, augments the problems caused by diabetes. Diabetes, high blood pressure, and high cholesterol in addition to smoking and a sedentary lifestyle increase manifold the chances of having a heart attack or stroke. Gangrene of the toes or fingers is actually similar and can be described as “an attack of the leg or hand”. This is because if not recognized timely and treated correctly, it may ultimately be a limb and life threatening condition. Amputation does not always stop at the toe.  Most patients eventually require an above knee amputation which increases the risk of fatality arising out of heart attack, pneumonia or wound healing problems. Studies have shown that after an amputation, 30% patients die in the first year after operation, 30% require an amputation of the other limb and only 30% remain ambulant.
What is also known is that diabetes is only one of the causes of gangrene. Smoking is the second largest cause, especially in young men even as young as age 30. A condition called Thromboangiitis obliterans (TAO) or Buerger’s disease is very much prevalent in India and other countries like Japan. It has been proved that the nicotine content in cigarettes and bidis is responsible for a chemical reaction which slowly destroys all the arteries and nerves of the body. Unfortunately, in India though there are awareness campaigns emphasizing that smoking causes cancer and impotence, it has not been stressed enough in media that smoking also causes gangrene.
In South India, thanks to efforts made by Government hospitals like Rajiv Gandhi Govt General Hospital, NGOs like Madras Diabetes Research Foundation and private hospitals like Christian Medical CollegeHospital Vellore and Bhagwan Mahavir Jain Hospital Bangalore, awareness is catching on. Patients are identified and many receive timely treatment which prevents amputations. However, the rest of the country still lags behind in awareness of the burden of disease and the resources available for treatment.
Treatment of gangrene to avoid a life-altering amputation is very much possible. However, timely recognition and proper referral to a centre with appropriate resources and dedicated vascular / cardiovascular specialist is essential.  General practitioners should avoid amputation of toes or the gangrenous segment if the peripheral pulses are absent / feeble as it only results in progression of gangrene. They should encourage the patient to go to a specialist as a limb and life threatening emergency.
Options available for treatment include open bypass surgery, endovascular options like balloon-plasty and stenting and ‘hybrid’ options (where both open surgery and endovascular ballooning are done in the same sitting). In angioplasty, a balloon is introduced from a puncture in the groin and used to open the block from within the artery. Sometimes, a stent is required to make sure that the artery stays open. Additionally, patients need to be on lifelong medications like aspirin and lifestyle management.
The results of these procedures are good and if adopted timely, prevents the trauma of amputation and helps in saving many limbs and lives.

Figure A. A picture showing gangrene of the left third toe in a 30 year old smoker. He required a bypass operation to save his leg.

Figure B. A picture showing blackish discolouration of the tip of his right great toe (pre-gangrene)in a 50 year old diabetic male patient. He improved after angioplasty of his arteries and did not require amputation.