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.
Learn How to Prepare for Dialysis
We recognize that the transition to hemodialysis can be a stressful time for many patients and their families.
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.
Dialysis Access Surgery FAQs
Your kidney doctor (Nephrologist) has determined that your kidneys have either failed or are very close to failing. Your kidneys play an important role in filtering out toxins from your bloodstream. When your kidneys can no longer do this task efficiently, these toxins can build up leading to illness and sometimes death. Dialysis is a means by which these toxins can be removed from the bloodstream. This requires access to your bloodstream. Although the veins in your arms and hands represent easy access to the bloodstream, they are too small and the blood flow too slow to perform dialysis. Therefore, we need to create a connection between these veins and the higher-pressure arteries in order to increase the flow and size through the veins over time which will allow for dialysis to occur. This requires surgery performed by your vascular surgeon. Ideally, this connection occurs directly between the artery and the vein (fistula), in your non dominant arm, as far away from the heart as possible (closer to the hand). However, the size of the veins may force us to make the connection further up the arm and sometimes indirectly using an artificial tube (graft) to connect the artery to the deeper veins. After a thorough examination and special ultrasound studies, your surgeon will determine the best option for access. This surgery is typically performed on an outpatient basis meaning you should get to go home the same day. It may take up to two weeks (graft) to 3 months (fistula) for the fistula to mature enough to be used for dialysis.
- You must take all prescribed medications as directed.
- Once it has been determined which arm is being operated on, it is very important that no IVs , blood draws or any other procedures are performed on that arm. We will typically provide you with an arm bracelet to remind you of this.
- Some patients may need be evaluated by the anesthesia staff prior to the day of surgery to make sure that surgery cab be performed safely the day of surgery. This visit will lower the risk that the surgery will be canceled. The anesthesia staff will review your chart prior to surgery and determine if an actual visit is necessary. Please make sure that you keep this appointment to avoid cancellation of surgery. The anesthesiologist will determine the type of anesthesia that is best for you.
- Nothing is to be taken by mouth starting at midnight the night before surgery except prescribed medications with sips of water. This includes water and coffee. We will inform you of the medications that should not be taken before surgery and when to stop them.
- You must arrive at admissions at the time listed on your instruction sheet. This is typically 1 to 2 hours prior to the scheduled time of your surgery. Failure to come on time may lead to the cancelation of your surgery.
- There are many factors, beyond the control of your surgeon, that determine when surgery actually starts. This may lead to delays. Please be patient with the staff as they try to get your surgery started as soon as possible.
- Family members/belongings: it is best to leave all items of value at home (cash, jewelry etc.). All items that are brought to the facility with you should be left with your loved one. All other items (clothing etc.) will be stored and given back to you after surgery.
- After the surgery is completed, the surgeon will come out and discuss how the case went. It is important that your loved one be available in person or by phone so that the surgeon can share this information.
- You will go to the recovery area for 30 minutes to several hours depending on The type of anesthesia you received and how quickly you recover from that anesthesia.
- After you have fully recovered from anesthesia, and it has been determined safe to do so, you will typically be discharged home at this time.
- You will not be allowed to drive or operate heavy machinery after you have been discharged from the facility.
- If you have a dressing, it may be removed 2 days after surgery. Replace with gauze and tape if there is drainage from the wound. You may shower after the first dressing is removed, without scrubbing the wound. Your dressing may be a transparent glue which should not be removed and will fall off on its own. This type of dressing may get wet the night of surgery.
- Mild to moderate swelling and bruising of the arm is expected.
- Some pain over the incision is also expected. You may be prescribed pain medicine to help control this. This pain may last a couple of days.
- Any major swelling, bleeding, severe pain in the hand, or inability to move the hand should prompt an urgent call to the doctor
- A follow up visit with the doctor, nurse practitioner or physician assistant should occur in 2-3 weeks after surgery.
- You will be scheduled an ultrasound study to be done around 6 weeks after your surgery. This will determine is the fistula is developing at an appropriate pace. The findings of this ultrasound will determine if some additional minor procedure is required to help the fistula develop appropriately.
- The fistula/graft should not be used for dialysis until cleared by your surgeon to be used
- It is important to know that all fistulas/graft eventually fail or at least is at risk for failing which requires close observation and occasional procedures to keep the fistula/graft working as long as possible
- If there are any questions, please visit the website at www.arteyandvein.com/FAQ
- For any other questions, call the office (407) 648-4323. Routine questions should be made between the hours of M-F 8 to 5 pm.
- Any urgent questions will be routed to the doctor on call after hours and on weekends.