Dialysis and Vascular Access Surgery
Patients with renal failure in the last stage have to undergo either kidney transplant or dialysis in order to continue their lives. While kidney transplant is the best option for today, not everyone has a chance to have a transplant or a suitable kidney transplant donor. In this case, the patient should start preparations as soon as possible to enter peritoneal dialysis or hemodialysis. In patients approaching hemodialysis, superficial veins in the arms must be made ready and suitable for dialysis beforehand.
Peritoneal dialysis or hemodialysis?
In fact, both methods have their own advantages and disadvantages. In peritoneal dialysis, where the peritoneum called the peritoneum is used as if it were a dialysis machine, the patient does not need a center, but does his own dialysis at home with the help of a catheter attached to his abdomen. However, in peritoneal dialysis, the clearance of toxic substances in the blood is limited, and there is always the possibility of infection of the abdominal membrane, even with care and proper cleaning.
In hemodialysis, the patient is treated in a dialysis center for 4 hours 3 days a week. The blood, in which toxic substances accumulate, is filtered with the help of a filter and cleaned of substances such as urea, potassium, ammonia and phosphorus, which are normally present in our body but become toxic when accumulated. The most important problem in hemodialysis is that the blood circulating in our body does not flow fast enough to enter dialysis. For this reason, patients can enter hemodialysis through either a fistula formed by joining the arteries and veins in their arms, or artificial vessels called grafts, or catheters attached to the neck or groin.
Since which method is the best method may vary according to the patient and the conditions, it is important to talk to the nephrologist who keeps track of you and decide together when choosing the most appropriate method.
So is it a fistula, graft or catheter when entering dialysis?
Do not do it. Remember, if a renal failure patient cannot be transplanted, they will survive as long as they can undergo dialysis. For this reason, the vein opening for dialysis is also a way of life for you!
Catheters attached to the neck are attached to the large veins that carry blood to the heart. If stenosis develops in these large vessels due to the irritation caused by the catheter, the arm vessels on that side become unusable. In other words, a catheter inserted into the neck of a patient who has just started dialysis renders the veins in the arm that can be dialyzed for 10-15 years inoperable within 1-2 years. Unfortunately, you will suddenly lose many precious years from your life. Therefore, in patients who will start hemodialysis, always;
“Fistula first, graft when no fistula option is left, and catheter as the last option should be preferred.”
What is fistula surgery, how is it performed?
Fistula surgery is roughly connecting a vein with an artery in the arm. The arteries with fast blood flow in our arm are deep and are not suitable for dialysis needle insertion. Blood flow is very slow in the surface veins. Do not forget that we are trying to meet the non-stop filtering and blood purification work done by the kidney 24 hours a day, 7 days a week, with the dialysis process, in which it can enter 4 hours a day, 3 days a week. So how do we do it?
Under local anesthesia, small incisions of 2-3 cm are made in the appropriate places decided by ultrasound on the arm, and the artery and vein are connected to each other. Thus, the blood in the arteries quickly passes into the superficial veins. Within 4-6 weeks, to adapt to this rapid blood flow, the vein both expands, and its wall thickens to accommodate the insertion of the dialysis needle. The preparations of the patient who comes to the hospital in the morning are completed. The operation takes about 45 minutes. As anesthesia is not given, the patient rests for 2 hours as a precaution, after making sure that there is no problem, a short training is given and sent home the same day.
How is graft (artificial vein) surgery performed?
If the vein that can be used for dialysis in your arms is not found or is no longer used, the second-best option is to perform surgery using grafts. Pre-surgery preparations of the patient who comes to the hospital in the morning are completed. The appropriate vessels to which the graft will be connected are determined by performing an ultrasound before the operation. If there are suitable vessels, the graft can be placed on the inner surface of the arm both below the elbow level and above the elbow level. It is placed just under the skin of the patient with a special tool and one end is connected to the artery and the other end to the vein that will take blood to the heart. The operation takes about one and a half hours. This time, the procedure is more comfortable for the patient by giving a sedative drug intravenously together with local anesthesia. After the operation, the patient is rested in his room for about 4 hours, after making sure that there is no problem, he is sent to his home after a short training.
What are the problems that can be seen after these surgeries?
One of the most common problems is that the fistula or the graft does not work. With a good preoperative planning in experienced centers, this rate can be reduced to less than 5% in fistulas and 10% in grafts. Another problem is bleeding due to blood thinners such as aspirin or heparin used. More often, infection may occur due to the foreign body used after graft surgery. The most troublesome situation is the low blood flow to the hand, which causes ischemia in the hand after surgery. Both fistula and graft surgeries are actually the process of stealing blood that normally goes to the hand and giving it to the vascular access created for dialysis. Therefore, disorders in the arterial structure of the patient or directing excessive blood to the dialysis vasculature may cause the blood supply of the hand to deteriorate.