What Are MIIPs?Permanent Dialysis Access


ATTENTION ALL DIALYSIS PATIENTS!

THIS INFORMATION COULD ADD YEARS TO YOUR LIFE, SO PLEASE READ CAREFULLY


THE FACTS

Your kidneys are vital filters for your blood and body. Without them you would die.

Now that your kidneys don’t work, you need a machine to filter your blood to keep you alive. This is called dialysis. Dialysis usually needs to be done several days a week, for several hours at a time.

For dialysis to be possible, you need an easy, reliable way to get the blood out of and back into your body.



THE OPTIONS 

Catheter:

A plastic tube that is placed in a vein. It has 2 channels--one to take blood out and the other to put blood back in.

Catheters can last for weeks to months—good short-term solution, not a good long-term solution.

Over time, the catheter can cause the vein to narrow or close off. If you keep using catheters for long enough, you will eventually run out of veins.


Fistula:

Surgeon hooks up a large vein in the arm to a nearby artery.

Over time, the vein becomes bigger—have to wait 6 weeks or more until it is ready to use.

Can last for years—good long-term solution.

Complications—read below.


Graft: 

Surgeon puts an artificial tube under the skin of the arm or leg—one end is hooked up to an artery and the other end is hooked up to a nearby vein.

Can be used soon after placement.

Can last for years, though usually not as long as a fistula—good long-term solution.

Good option if there are no good veins available for a fistula.

Complications—read below.


Peritoneal Dialysis:

Doesn’t use blood. A large plastic tube is put into abdominal cavity. Fluid is put into the cavity through the tube, then sucked back out.

Not as effective as hemodialysis, which uses blood.



COMPLICATIONS

Blood clots can block the veins, graft or fistula and prevent blood flow, making dialysis impossible.

Over time, scarring can develop in the fistula, graft or veins. This can slow down or block blood flow, making dialysis difficult or impossible.

Weakening of the wall of the fistula or graft, which can cause ballooning (aneurysm), a contained leak (pseudoaneurysm), or rupture

Infection of the fistula or graft

Pain or weakness in the arm or leg. This can happen if the fistula or graft steals blood away from the arm or leg.

The fistula doesn’t get big enough to use. This is usually because of small vein side branches draining blood away from the fistula.



THE OUTCOME

When the fistula or graft doesn’t work, it needs to be fixed or replaced. In the meantime, you may need a temporary dialysis catheter.

Every fistula or graft has a limited lifespan. You only have a limited number of places you can put a new one. Once a site is used up, it is usually gone for good.

As a result, each graft or fistula needs to be kept in working order for as long as possible.



HOW TO TELL IF THINGS AREN’T WORKING RIGHT

When a fistula or graft starts to fail, it doesn’t usually happen all at once. Problems the dialysis machine can detect:

    • Decreased blood flow
    • Increased blood pressure
    • Decreased filtering

Problems with the fistula or graft you can feel or see:

    • Too soft/not full enough
    • Very strong pulse
    • Weak or no buzzing feeling (“thrill”)
    • Pain during dialysis
    • Bleeding from punctures for a long time after dialysis needles are removed

Once these problems show up, it’s important to get checked and treated as soon as possible before they can get worse.

Ultrasound can help diagnose many of the complications listed above.

Most complications are visible on an angiogram, or moving X-ray pictures taken while injecting a contrast “dye” into the graft or fistula through a skin puncture.



TREATMENT 

Surgery

Can treat many but not all the complications listed above. There are some places where complications happen that the surgeon can’t easily reach.

Risks of surgery are from being cut open, anesthesia, and scarring from healing that can cause new narrowing or blockage in your veins.


Newer techniques by IR

Interventional Radiologists, or “IRs” for short, are doctors specially trained to do minimally invasive, image-guided procedures (MIIPs) using moving X-rays or other medical imaging to see inside the body.

IRs fix problems through needle punctures through the skin, without surgery.

IRs have developed newer MIIPs to treat the complications listed above. These MIIPs are performed through small plastic tubes put into the graft or fistula through pinholes in the skin – no big cuts.

Usually all that’s needed is numbing medicine injected in the skin and sometimes IV pain medicine and medicine to make you sleepy—no general anesthesia involved.

Blood clots can be removed using clot-dissolving medicine, suction, devices to break up the clots (like roto-rooters), or a combination.

Narrowing and blockages can be treated by blowing up a balloon inside to stretch the area back out to normal (angioplasty), putting an expandable metal mesh tube (stent) inside to hold the area open, or both.

Aneurysms and leaks can be treated by putting a special stent across the area to seal them off but keep the graft or fistula open.

Vein side branches can be plugged from the inside by an IR or tied off during surgery to channel all the blood flow through the fistula.

Some problems can’t be treated successfully by an IR. When that happens, you’ll be sent to a vascular surgeon.



ADVANTAGES OF IR TECHNIQUES

Safe – low chance of damage to the graft or fistula, less need for anesthesia. 

Fast, getting you back to dialysis sooner.

Easier access to treat complications in hard-to-reach places.

Longer lifespan for each fistula or graft.



THE TAKE-HOME

Pay attention to how your dialysis fistula or graft is working, looking, and feeling. If something is wrong, see your nephrologist or IR right away. The longer you wait, the more complicated things tend to get and the harder they are to treat.

Insist on the best, safest, most advanced treatment.



For more information on hemodialysis fistulas and grafts:



For more information about kidney failure:



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