Transcription:
Fistula Procedure

Progressive, respectful, mentoring, compassionate, these are the values of Palmdale Regional Medical Center. And now, we proudly present Palmdale Regional Radio. Here's Melanie Cole.

Prakash Chandran: Welcome to Palmdale Regional Radio. My name is Prakash Chandran. And today, we will be discussing fistula procedures. Joining me today is Dr. Phong Dargon, a vascular surgeon and a member of the medical staff at Palmdale Regional Medical Center.

First of all, Dr. Dargon, really great to have you here today. Let's just start by you providing us a little bit of background on what exactly a fistula is.

Dr. Phong Dargon: Sure. Well, thank you for having me on the show. Arteriovenous fistula or AV fistulas are a way for patients to do hemodialysis. And generally speaking, there are two ways that people can do dialysis using their arm, either a surgically created vein is moved and connected to an artery to form an artificial circuit to create dialysis access, or if a patient doesn't have any usable vein that we sew in what's called a graft. And one end of the graft to sewn into the artery, the other end is sewn into the vein, and that provides immediate access for dialysis. So these are generally surgically created abnormal connections between an artery and vein to provide a way for patients to have hemodialysis.

Prakash Chandran: Okay. Great. And just for those of us that haven't heard of the term hemodialysis before, can you just give a high level explanation for what that is?

Dr. Phong Dargon: Sure. So, unfortunately there are a lot of patients who have renal failure, so meaning their kidneys no longer work. And the kidneys are very important organs in the body that helps regulate fluid balance, electrolyte balance, and also help in the process of forming red blood cells. So unfortunately, when someone's kidneys no longer work and they fail, they have to be put on some form of dialysis to maintain life essentially. So, vascular surgeons and nephrologists are kind of key players in helping patients in this journey.

Prakash Chandran: Okay, that makes a lot of sense. So what type of patient is typically diagnosed for needing a fistula procedure?

Dr. Phong Dargon: Well, there are generally two types of patients. One patient in the ideal setting is one who has been monitored for quite some time by nephrology as identifying as needing dialysis access in the future. Those patients, we call them pre-dialysis. So in a perfect world, you meet a person who does not need dialysis yet, but they know that they'll need dialysis soon within three months or so. And then when they meet with me or my partner, we create the access, get it up and running before they actually need the circuit.

A second group of patients, unfortunately, are people who had no idea that they had kidney problems and are admitted to the hospital emergently with complications of fluid overload or cardiac issues or pulmonary issues stemming from their unknown kidney disease. In that situation, they start dialysis immediately with a catheter or a fake tube in their vein. And then eventually, we play catch up and create the surgical access. So those are the two types of patients usually.

Prakash Chandran: Okay. And just speaking about fistula more broadly, like we're talking about largely things around the kidney or surrounding the kidney right now, does fistulas affect any other area of the body?

Dr. Phong Dargon: Absolutely. So, since the kidneys regulate fluid balance in the body, if someone's kidneys fail and they didn't know that, they can often come in with cardiopulmonary problems, meaning they can be in fluid overload and cause extra stress on the heart. The lung cavities can fill with extra fluid, making it very hard to breathe. Oftentimes these patients are anemic because the kidneys play a key role in sending off hormones to regulate creation of red blood cells and electrolyte balance. So derangements in electrolytes can also cause cardiac arrhythmias that can also be fatal.

Prakash Chandran: So we talked about kind of the two use cases, I guess, for the most common types of fistula procedures. Talk now a little bit at a high level about the different procedures that are available and how a patient gets started.

Dr. Phong Dargon: So if someone needs emergency dialysis, the catheter gets put into their vein, a major vein, and they can start emergency dialysis that way. There are two types of catheters, ones that are only used in the hospital and ones that are called tunneled and that type of catheter, the patient could leave the hospital with that catheter and continue dialysis that way.

Generally, we'd like to get these catheters out as soon as possible because they can pose a risk for infection, bacteremia, and overwhelming infection of the bloodstream from head to toe. So that can be very dangerous. And the catheters themselves can also cause damage to the vein that they're inserted in. So ideally, we'd like to get some sort dialysis access created as soon as possible and get these catheters out as soon as possible.

And like I had mentioned before in a perfect world, someone is identified as being pre-dialysis, not on dialysis yet, but known to need it in the near future, we create the surgical access, get that up and running before they actually need it. So they're all different types of patients that get referred to us. Some of them who have already started dialysis in the hospital and have left the hospital, and those who are referred in the clinic setting who are not on dialysis yet, but know that they will need it soon.

Prakash Chandran: Okay. And which part of the body is the fistula or the graft most commonly implemented?

Dr. Phong Dargon: So, fistulas or grafts, they're created in the non-dominant arm as far down to the wrist as possible. And the reason why we choose non-dominant arms is because during dialysis, the patient's arm needs to be kept very still as two large needles are inserted into the actual circuit to be hooked up to the machine for dialysis. And what I usually counsel my patients is it would be a bummer for me to put the circuit in their dominant arm and then they have to leave it out and still for two and a half, three hours. And then they have to rely on their non-dominant arm to read a book, watch DVD, or do things with a non-dominant. So that's why we prefer to put the access in the non-dominant arm, knowing that these circuits, they have a lifespan, they don't last forever. So when the circuit no longer works, we have to create a new one somewhere else. And the mantra is we try to create one as far downstream as possible, because if and when it fails, we need to move up the arm and create somewhere else. You can't create one closer to the shoulder and move down to the wrist. It just doesn't work that way. So we try to start as far down as far as the wrist as we can and working our way up.

Prakash Chandran: Okay. And this passage way that's being created, I think I'm trying to get a good understanding, is this something that is left permanently in the arm after it's done, or is it removed after some period of time? Like how does this typically work?

Dr. Phong Dargon: Usually, it's permanent. Depending on certain circumstances, we sometimes will be asked to undo our work. And in that situation, which is usually a good situation, is when someone no longer needs it. They just got a kidney transplant, the kidney's working great, they no longer need their fistula. And so that's one situation where we would actually undo the creation of the fistula.

There are other more rare circumstances like fluid overload, congestive heart failure that's worsened because of the presence of the fistula. Sometimes infection will cause us to go on and undo things. And sometimes in rare circumstances, something called steal syndrome. So imagine a fistula that's working so strong that's actually sucking blood away from the hand like a vacuum and the hand is suffering. There are maneuvers to do to try to save the fistula and increase flow to the hand, so you have the best of both worlds. But in dire situations, yeah, we could also remove the fistula to save the hand.

Prakash Chandran: Okay. So let's talk a little bit about the recovery time of these procedures. And I know it's kind of dependent on which one, but what can a patient for the most common procedures expect?

Dr. Phong Dargon: So, the creation of a fistula or placement of a graft is an outpatient day surgery elective type of procedure. The usual timeline, let's say if someone's pre-dialysis, they meet me in the clinic. We go over the actual procedures, pros and cons, risks and benefits. We sign them up for date and time for surgery, outpatient setting in the hospital usually, or depending on different areas of the country, this would be a day surgical center.

The procedure itself can take anywhere between 45 minutes to maybe hour and a half, all depends on the anatomy. Has anyone been there before? Is this brand new territory that no one's ever operated before? How easy is it to get to the vein? But usually, the surgery is anywhere between 45 minutes to an hour and a half. The type of anesthetic totally depends on how sick the patient is, patient comfort and anesthesia comfort. So I've done this procedure with just very light sedation, twilight sedation with a lot of local anesthetic to as far as much us general anesthesia. So, breathing tube, the whole bit, a hundred percent knocked out.

Usually straightforward procedure, not much flood loss. Recovery room, probably about 45 minutes before being able to discharge. And bandages are only on where the areas of incision exist. And usually, I always give pain meds for this procedure, but rarely do people need it. I think it's because the incision is small, not too much dissection. And yeah, patients generally tolerate it very well.

So this is a day surgery procedure, in and out the same day. And then depending on the circuit, if it's a fistula and things go well, now we're in the waiting game. And what I usually tell patients is just because the vein is now hooked up to the artery, it does not mean it's ready for prime time use. Now, we have to wait for that little vein to get big enough, strong enough and thick enough to be able to use for dialysis and be able to handle being poked by two large needles. And that waiting time can take anywhere between one month to up to three months typically before it's ready for use.

Now, if the patient had no usable veins, then plan B is to put in the graft. The graft is an artificial base of a tubing, sterile, off the shelf. It's already the right size. And we put that all underneath the skin. And like I said before, sew one end into the artery, sew one end into the vein and then you have your instant access. And the neat thing about the graft is you can use it within 24 hours. So, those grafts are great for people who previously would have never had any options because their veins were just too small, but the graft has allowed those patients to get dialysis.

Prakash Chandran: So, I guess, related to that, it sounds like the graft is a much quicker turnaround. So why wouldn't people just opt for that to begin with?

Dr. Phong Dargon: Sure. There are pros and cons of fistulas and grafts. So the way to break it down is fistulas, the downside is you got to wait for it to grow. So it can take one, two or three months and it might not even work, so that's a bummer to have to start all over if it doesn't grow big enough and strong enough for dialysis. The pro of a fistula is a good fistula will last you easily 5 to 10 years. And since it's all natural, we're using the patient's body parts, infection rate is extremely low. I don't think I've ever seen a fistula get infected because it's all natural. So those are the pros and cons of a fistula. Slow to get up to cruising altitude, but once we're there and it's working great, it's going to last you easily 5 to 10 years.

Now for grafts, the pro of the graft is back in the day before they were invented, it provides a person a way to do dialysis using the arm and get the catheter out. So before the grafts were invented, if the patient didn't have any good veins, we would say, "I'm sorry. You're just going to be stuck with a catheter for the rest of your life and just accept the risk of infection." But the grafts these days, the pro is it's a way to get dialysis without using the catheter. The con is since it's fake, it's always got risk of getting infected. And I try to put the fear of God into them, you know, using really good hygiene, watching it like a hawk. Because should the graph get infected, the whole thing's got to come out and you got to start all over again, which is a bummer.

Prakash Chandran: Yeah, I see.

Dr. Phong Dargon: Oh, and I forgot to mention, the other thing about grafts is they don't last as long. Maybe two to five years, depending on the type of graft. The technology, isn't there to meet fistulas head to head, you know, 10-year range and stuff like that.

Prakash Chandran: Got it. So am I correct in assuming that typically the first line of defense is the fistula, but if the fistula doesn't work, like the artery is too small, then you'll consider the graft.

Dr. Phong Dargon: Exactly. And that is one of the government mantras and guidelines for dialysis access. The saying used to be "Fistula first at all costs." But then they realize, you know, not everyone's the same, everyone's situation is different. Sometimes a graft in a particular patient and their setting might be more beneficial than the fistula, but the bottom line these days is whatever it takes to get rid of the catheter.

Prakash Chandran: Got it. And one thing just around that waiting period, once you get the fistula, I know you said it could take, you know, one to three months, what can someone expect? Like will there be a bulge in their arm? Will it be painful? Like what are some of the most common things that people report?

Dr. Phong Dargon: Two things to look for, which I like, and signs that it's working. Number one, you're going to feel kind of a buzz or a thrill. Some of my patients say when you put your hand on the actual surgical site, you feel kind of like a rumbly tummy, almost like a kitten is purring underneath it. So that's actually a good sign because that means the artery blood is mixing with the vein blood and heading back to the heart. So when you feel the thrill or the buzz, that's a very good thing. And I tell my patients, you know, "Check your fistula every day. The minute you don't feel that buzz, give me a call," because that means we've got to go in and try to save that fistula.

The other thing that you might notice is the actual vein that used to be small and farther away from the skin, well, that should larger and stronger and thicker. And then you might be able to even see it at the skin surface. And that's exactly what we want because we want the vein to be visible, to make it easier for the dialysis technician to actually poke it with a needle because a fistula, that's hard to feel and you can't see, very hard to get into. But a fistula that's very strong, you can feel the buzz and you can actually see the actual vein, that's a good fistula.

Prakash Chandran: Okay. So Dr. Dargon, now that we have a good understanding of how fistulas have been done traditionally, I hear that there is a new method that I was hoping that you could talk us through.

Dr. Phong Dargon: So, as I mentioned before, the "old-fashioned way" of creating a fistula is take someone to the operating room, disconnect the vein and hook it up to the artery. That is old surgery since like 1966, I think was the first time the fistula was described. The newer way is to do it totally percutaneous, all through needle pokes, wires, magnets and x-rays and creating the fistula, totally incisionless. And that creation is pretty neat because it's done in a totally different circumstance.

So before, I mentioned how this surgical fistula is created in the operating room setting with either moderate sedation or full-blown general anesthesia, and that involves cutting, scarring, blood loss, and a lot of patients don't like that. I'm one of the few people in the county who actually knows how to create a fistula totally with needle pokes and that procedure looks very different for the patients.

They go to the cath lab. The cath lab is the other part of the hospital where patients with heart attacks or problems with circulation or flow, they go to that area of the hospital. The procedure is done under moderate sedation. And with that, twilight sedation, way less stress on the heart, so the risk of heart attack is drastically reduced. And when done, the patient just wakes up with two Band-Aids and that's it. Hardly any pain because the procedure is done with two needle pokes and it's a pretty slick procedure. This was first studied around 2016 to 2018 overseas before getting FDA approval. And it's really hit prime time use within the last year and a half to two years now.

Prakash Chandran: I can't even wrap my head around how that works, just this incisionless way of doing things. That's incredible.

Dr. Phong Dargon: Exactly. It's really slick. So with ultrasound guidance, I enter into the person's artery and vein using a needle. And then, I slide a wire through that needle, take the needle out. And now, the wires might railroad track. There's a special tube with magnets on it. Under x-ray, I slide the tube over the wire. And under x-ray, the two tubes or catheters align because there are magnets. And with a little jolt of electricity, the fistula is created. We slide out our instruments, hold pressure, and we're done.

Prakash Chandran: Yeah, that is incredible. So is this new type of fistula procedure called something specific?

Dr. Phong Dargon: Yes. It's called endovascular AVF creation or EndoAVF is what we call it. The device I use is a BD WavelinQ, W-A-V-E-L-I-N-Q. That's the device that our practice and Palmdale Regional has chosen to use. And I love it because it's pretty straightforward. There's a little bit of a learning curve, but it's able to extrapolate a skillset that I already had, poking very small arteries near the ankle. And now, when I'm asked to go ahead and poke a small artery and vein at the wrist, no problem. You know, I have experience doing that, so it's not that much different. And the device is very easy to use. Our success rate has been very good. Technically, only one patient that we tried did not work and that person we were already kind of on the fence whether or not to recommend this procedure.

And one thing I didn't mention is unfortunately not everyone qualifies for this fancy fistula procedure. We have to get a special ultrasound to see the patient's anatomy and to see if the vein is the correct size, correct configuration to see if we can even do this. So typically, these are patients who are pre-dialysis, who haven't had their veins worked on before, who may or may not qualify. And this one patient, I remember being on the fence and I thought, "You know what? Let's just give it a try. If it doesn't work, you know, no bridges are burnt." But otherwise, the other six patients that we have done this on within the last year, all of those fistulas had success of creation in the cath lab. And they're at various stages of healing and awaiting dialysis.

Prakash Chandran: Wow. That's incredible. So just one more time, if someone is considering getting a fistula procedure done, what should they ask for specifically at Palmdale Regional Medical Center?

Dr. Phong Dargon: Ask for the fancy fistula with no cutting.

Prakash Chandran: The fancy fistula with no cutting. I got it.

Dr. Phong Dargon: Exactly. It's funny though, the patients who are sitting in dialysis next to each other, when they hear that, "Hey, someone got the new fancy fistula." They're like, "I want that, doc. I want my fistula made that way." So it's really the incisionless fistula creation.

Prakash Chandran: Well, that is just so cool, Dr. Dargon. Just before we close, is there anything else that you wanted to share with our audience here today?

Dr. Phong Dargon: No, I just want to thank you for inviting me to your show. Dialysis work is something that I'm very passionate about, me and my partner, Dr. Chauvapun, and our group name is called Vascular Associates of Southern California in case anyone is trying to find out where the heck is this Dr. Dargon? Where's he hiding? Where is he? But Vascular Associates of Southern California, and we have close relationship with a local nephrologist to help all our patients get the care that they need.

Prakash Chandran: All right. Well, Dr. Dargon, thank you so much for your time today.

Dr. Phong Dargon: Thank you.

Prakash Chandran: That's Dr. Phong Dargon, a vascular surgeon and a member of the medical staff at Palmdale Regional Medical Center. For more information, please go to our website at palmdaleregional.com, go to the surgery section and then search vascular surgery.

That concludes another episode of Palmdale Regional Radio with Palmdale Regional Medical Center. For more health tips and updates, follow us on your social channels and remember to subscribe, rate, and review this podcast and all other Palmdale Regional Medical Center podcasts. Finally, please share this on your social media and be sure to check out all the other interesting podcasts in our library.

Physicians are independent practitioners who are not employees or agents of Palmdale Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. Thanks again for listening. My name is Prakash Chandran, and we'll talk next time.