End Stage Renal Disease (ESRD) is the irreversible loss of kidney function. The two most common causes are Hypertension (high blood pressure) and Diabetes. The treatment for ESRD is either Kidney Transplantation, or Dialysis and can be done through the Bloodstream (Hemodialysis). As Vascular Surgeons, we are asked by Kidney Doctors (Nephrologists) to provide the means (Access) by which Dialysis can be accomplished.
Hemodialysis, on the other hand is typically done in an Outpatient center, three times a week. In order for the dialysis machine to be able to clean the blood, a means of access to the blood stream that allows for high flow rates is required.
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A tube can be placed in the Jugular Vein in the neck (Perm-catheter), generally considered to be used for weeks to months. It is preferable however, for durable and prolonged function, to have the access in the arms.
There are two types of access for the arms: fistulas and grafts.
Fistulas involve connecting the patients own artery and vein, to create a high blood flow system.
There are typically three types of fistulas: Radio-cephalic, Brachio-cephalic, and Brachio-basilic transposition, named for the various connections.
The placement of an Arterio-Venous graft on the other hand, involves using an artificial tube that is connected to an artery and vein. Fistulas are generally preferable to grafts, and we as Surgeons, are always committed to whatever we can to place a fistula.
These lumps are called pseudoaneurysms. Due to the repeated needle sticks that are necessary to perform dialysis through a fistula, blood may leak from a tiny hole in the fistula into the tissue. This creates pockets of contained blood that make the arm appear lumpy over the fistula. Though they are cosmetically unappealing, they are not necessarily medically concerning unless they become painful, affect dialysis, cause erosion of the overlying skin, or become in any other way symptomatic. Rotating the sites where the fistula is accessed can result in less trauma to the fistula and decrease the risk of pseudoaneurysm development. Should you develop pseudoaneurysms or if you have any other concerns regarding your dialysis access feel free to make an appointment for a vascular evaluation.
This is an excellent question. Hemodialysis involves using a machine to remove the blood from the body, cleanse it of waste products/excess water (as the kidneys would normally do), and return it back to the body.
Normal veins are much to small to tolerate this large transfer of blood. Therefore, a fistula must be created. A hemodialysis fistula is a surgical connection between an artery and a vein. The arterial flow is shifted into the vein which causes the vein to grow.
This large vein can be accessed with needles for dialysis. It is very common for the nephrologist to recommend a fistula be created prior to the start of dialysis. This is because it takes a while (six weeks to several months) for the vein to grow to the size that is necessary for it to be successfully used for dialysis. If an individual needs dialysis and does not already have a developed/mature fistula, then it is necessary to insert a catheter directly into a vein in the chest. The blood would then be drawn directly from this catheter for dialysis. This is not ideal as the catheter poses a risk of infection and can be damaging to the veins.