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Melanie Cole, MS (Host):   Welcome. This is Stoughton Hospital Health Talk. I'm Melanie Cole and today we’re talking about AV fistulas for dialysis. Joining me is Dr. Aaron Schwaab. He’s a board certified general surgeon at Stoughton Hospital. Dr. Schwaab, it’s such a pleasure to have you joining us today. Tell us a little bit about dialysis vascular access at first. What is it that people can expect as far as timeline and the types of access that you need if someone’s going to undergo dialysis.

Aaron Schwaab M.D. (Guest):   When I see patients they’ve typically been told by their nephrologist to go see the surgeon because it’s likely you're gonna need dialysis access in the near future. So when I talk to patients about hemodialysis—What hemodialysis is when they have to hook the patient up to a machine that’s going to pull the blood out of their body and filter it and then put it back in. That’s really doing the job that the kidneys are doing. In order for the machine to be able to pull the blood out of their body and filter it and put it in quick enough we have to access to a fast flowing circuit of blood in the body. That is why we can't just put an IV in someone in their arm or their hand and do dialysis because their veins are too small, and they just don’t have enough flow in them.

So in order to get access to that fast flowing circuit, there's really three options. There's what's called the dialysis catheter, there's an AV graft, and an AV fistula. A dialysis catheter is basically a plastic tube that’s put in at the chest or the neck of the patient. The tip of that catheter sits down by their heart in the biggest vein in the body called the vena cava. It’s quite large. It’s like a garden hose. It’s got a lot of blood flowing through it. So they can hook patients up to that immediately and start using it. So that’s the nice thing about those catheters. The problem with them is that they can get blocked or infected. So they don’t typically last very long. The lifespan is about six to 12 months on one of those. If we’re looking at an AV graft or an AV fistula, basically what those are without getting too detailed if we’re going to hook an artery and a vein together in someone’s arm so that the blood which is flowing in an artery very quickly and under pressure can flow directly into the vein and create this fast flowing circuit. The difference between the graft and the fistula is the graft uses a plastic tube to hook the artery and the vein together whereas the fistula is just hooking the artery and the vein together directly. The best system that we have is the fistula because we’re not implanting any plastic in your body, so we don’t have to worry about infection. It’s just your own native blood vessels. The fistula, once you get a nice fistula, they can last for several years. So that’s really the ideal system for dialysis.

Host:   Are there some people for whom a fistula is not an option and they have to stick with that initial shunt? Tell us a little bit about some of the complications first that could come with a shunt and who might not be able to get a fistula?

Dr. Schwaab:   The problem with the catheter again is that because it’s a plastic tube in your body it’s going to eventually get infected or it’s eventually going to get clogged. Then they have to take it out and put a new one in. Again, the life span is about six to 12 months. The problem is each time you put one of those catheters in it creates scar tissue in and around the veins that it’s sitting in. Eventually after two, three, or four catheters it can be very difficult to get a new catheter in someone. So I've actually seen patients who have had catheters for five years and they may have had seven or eight catheters in that time frame. Now we can't get a catheter in them. So now that person needs dialysis and we’re in trouble because we can't get an access in them.

So as far as the fistula goes, really the patients who might struggle with the fistula are patients who have really small veins. So their veins are just so small that we can't sew them together well enough that there's going to be a good enough flow. That’s probably the most common thing we see. You have to remember that a lot of these patients are obviously sick. They’ve been sick for a long time and they’ve had a bunch of IVs. Their veins are kind of damaged from all of this blood draws and IVs they’ve had in the past. So sometimes their veins just are not adequate. We just can't sew them together or their veins have a bunch of blockages in them or scar tissue from all the IVs they’ve had. So that’s probably the most common problem we have. Otherwise there's people who’ve had surgeries on their arms that have damaged their veins, or they’ve had PICC lines, which are long standing IVs which have damaged their veins. We also see people who have had pacemakers in. Those pacemakers can cause narrowing in the veins up in their chest which can make it that a fistula isn’t going to work on that side. So in those patients, are options are to try and use a graft, which the plastic tube, to substitute for someone with small veins or veins that doesn’t work.

The other complications with someone with a fistula is the longer you have a fistula, that vein will continue to kind of get larger and dilate. It can even turn into what we call an aneurism where the vein has become so dilated and stretched out that it’s this large sack underneath the skin. Those are at risk to bleed or rupture. That’s usually a problem for people who have had a fistula for a long period of time

Host:   If someone has a fistula, how long does it take until that can be used for dialysis access? What do they do in the meantime?

Dr. Schwaab:   A fistula because when we’re hooking that artery and vein together, the vein starts out and is maybe an eighth of an inch in size or three or four millimeters. We have to wait for that vein to stretch and dilate and get bigger now that it has that fast flow with the pressure going through it. That takes a minimum of two months. So for my patients when I make a fistula, I tell them it’s going to be a minimum of two months before it could possibly be used. It could take longer. It can sometimes take three, four, five months. So in the meantime those patients are going to have a catheter in. So the catheter is kind of the fallback safety net for people who are waiting to get their fistula up and running. They can have that catheter for several months. Once their fistula’s ready we can transition them from being hooked up with a catheter to their fistula. Once their fistula’s working we can take their catheter out.

Host: So you mentioned some of the risks with the catheter. While they’ve got that in and while they're waiting for the fistula to work, what are some things you would like patients to know that they can and can't do? What are some important recommendations for keeping it clean or showering? Swimming? Things that they need to think about doctor.   

Dr. Schwaab:   Typically they're going to get pretty strict instructions from the dialysis centers about that, but generally they keep a bandage on it. The dialysis centers are going to teach them how to care for that. These people are going into the dialysis center usually three days a week. So the nurses at the dialysis center are going to change and look at the catheter every day, but they are generally told that they can't shower because they don’t want to get that site wet. They certainly can't swim. In that case, it can be pretty limiting. They also are usually counselled about what signs and symptoms to watch for. So if you're having fevers, especially after they use the catheter in dialysis. If someone starts having shaking chills or fevers, that can be a sure sign that the catheter’s infected. Then when the dressings are changed, they're looking to obviously make sure that there’s no redness or tenderness over the catheter site. When those catheters are used, they have to be used with very careful sterile technique so that we don’t contaminate the catheters. You have to realize that those catheters go directly into someone’s bloodstream. So if they do get bacteria in them you're basically putting that bacteria right into someone’s bloodstream, which is a very serious infection.

Host:   What would you like patients to know about the procedure itself to put in the fistula? Dr. Schwaab as you are doing this at Stoughton Hospital, what would you like them to know about what they can expect and what questions you want them to ask?

Dr. Schwaab:   Most people are not looking forward to going on dialysis. This is all very new to them. A lot of them are blindsided. They come into my office sometimes a little bit in shock and certainly very frightened about what’s this surgery going to entail? I spend a lot of time trying to reassure them this is actually a pretty simple straight forward surgery. We do them under sedation, so we don’t have to put them asleep completely. It takes about an hour. They get to go home the same day. Really within a day or so they're back to their normal activity. There's really not any specific activity restrictions that we put on them. The post-operative discomfort from the surgery is very mild. I like to tell some of my patients they’ve probably cut themselves work in the garage or in the kitchen. It’s about a one inch cut. So really this surgery is not much to be afraid of.

As far as questions that they should ask when they come in, they want to know what are things I need to worry about as far as potential complications or risks. The biggest one that they need to realize is that unfortunately not all of these fistulas work when we create one. We’re hooking an artery and a vein together, which is an unnatural thing in your body. I tell patients it’s usually about 80 to 90% of the time this actually works, but that 10 to 20% of the time it may not work. It may not work because their veins or small or they have scar tissue in their veins. If that happens, we may have to try again. So I like to make sure that people realize that upfront that this isn’t a surefire thing. Thankfully it’s not a really invasive surgery that people are out of commission for several days or weeks because of it.

Host:   Do you have any final thoughts Dr. Schwaab? You're such a great guest with so much good information. What would you like listeners to take away from this. If they are someone that has been told that dialysis is in their future, what would you like them to know about what they can expect from this whole process?

Dr. Schwaab:    Well two things Melanie I’d like to say is number one if you’re told that you have poor kidney function and that you may be on the path to dialysis, that has to be a big slap in the face that they need to do what their doctors tell them, their nephrologists and their primary doctors. Watch their blood pressure, manage their sugars if they have diabetes. Because if you can watch this and realize that your kidneys are damaged and make some lifestyle changes, you can stop the process in many cases and not end up on dialysis. Dialysis becomes a way of life. You basically are spending three and a half to four hours three times a week sitting in a chair getting dialysis. It becomes your job basically. So if you're warned by your physician that you need to make some changes or you're going to end up on dialysis please listen to them and take it seriously so that you can avoid the whole process.

Also for patients who have diabetes and have high blood pressure who are younger, I can't tell you how many patients I see who say to me—they're in their 60s now—and they say, “God, I wish my doctor would have told me that if I didn’t control my sugars or my blood pressure 20 years ago I would be sitting here needing dialysis. I wish someone would have really told me that.” So that’s really the message I want to get out. The two big culprits that we see are patients with diabetes who don’t control their blood sugars and patients with high blood pressure who don’t control their blood pressure. So those patients who are going to their doctor and being told their blood pressure’s too high and their sugars are bad, please listen to that and make the lifestyle changes that you need because I promise you you're not going to want to retire with all of these plans to go do all of this travelling and then be tied to a dialysis machine for the rest of your life. So that would be my big message for people.

Host:   What a great message it is. Thank you so much, Dr. Schwaab, as always. Really, really great information and so important for listeners to hear. That concludes this episode of Stoughton Hospital Health Talk. Please visit our website at stoughtonhospital.com for more information and to get connected with one of our providers such as Dr. Schwaab. Please remember to subscribe, rate, and review this podcast and all of the other Stoughton Hospital podcasts. I'm Melanie Cole.