Scope of Practice

Hemodialysis Vascular Access Maintenance Procedures

We specialize in maintenance procedures that restore blood flow to dysfunctional dialysis accesses. Pump blood flow of at least 400 ml/min for fistula and grafts and at least 350 ml/min for catheters is necessary to maintain optimal dialysis clearance measured as Kt/V above 1.4 or urea reduction ratio above 65%.

Development of blockage in the dialysis circuit, also known as stenosis, is the primary cause of reduced blood flow or poor clearance. Other symptoms of stenosis also include high venous pressure, hyperpulsatility, high negative arterial pressure, high recirculation, prolonged bleeding, difficult cannulation, infiltration, pulling clots, pain the access or arm, swollen extremity, pulling clots, clotted access, aneurysmal expansion, numbness, tingling, or ulcers in fingers of the access arm, etc.

Each dialysis unit needs to have a vascular access strategy in place that prospectively identifies these problems so that early diagnosis can be made and treated before the access clots. The access center works in close collaboration with dialysis centers to diagnose stenosis in symptomatic accesses using x-ray equipment to visualize problems and solve them with balloon angioplasty (dilatation) and stents. We use MINIMALLY INVASIVE techniques that are designed to be EXPEDITIOUS with the goal of RETURN TO DIALYSIS as soon as possible.

Our maintenance procedures include:

• Angiograms / FistulogramsFor diagnosis — we inject contrast material into the access to check blood flow and identify areas of blockage (stenosis).
• AngioplastyIf we find a blockage, we place a balloon at the blocked area and inflate it to dilate the blockage and open it.
• MaturationThis is a terminology used to describe gentle angioplasty on small non-maturing or poorly developing fistulas to help them mature or develop. It could take up to 3 sessions of gentle angioplasty, 1-2 weeks apart, to get the vein to a size and flow that is ready for needle placement.
• StentsSometimes angioplasty alone is not enough to keep the blockage open, so we place wire mesh devices called stents in the blocked area to keep the blocked area open.
• Declotting / ThrombectomyWe use a combination of balloons and stents as well as blood thinners to remove the clots and restore blood flow
• Banding / Flow ReductionSometimes the blood flowing into the access is more than the part flowing into the fingers causing the finger to suffer from low blood flow. Symptoms include pain, numbness, tingling and sometimes ulcerations or gangrene looking fingers. This is often called Steal Syndrome (the access is stealing from the fingers). When we make the diagnosis, we are able to go into the inflow segment of the access and narrow it down to move more blood into the fingers.
• Embolization of Accessory VeinsSometimes there are many side branches draining the fistula, which prevents the fistula from developing. When we make this diagnosis, we are able to find those branches and remove them allowing all the blood to flow in one direction to develop the fistula.
• Tunneled Dialysis CathetersIf a patient has a dialysis catheter that is not flowing properly, infected but treated or the skin has broken down, we will replace and repair the skin as needed. If the patient had a dialysis catheter and now has a functioning fistula or graft, we will remove the catheter. Catheters that have been in place for a long time can damage the blood vessels, so the sooner a fistula or graft is placed, the sooner the catheter can come out. We will also place new catheters when there is a need to continue or initiate dialysis