Be a competent vascular access interventionist
A few words for interventional nephrologist colleagues
Interventional nephrologist is a relatively new subspecialty in recent years. Among the procedures commonly practiced by interventional nephrologist, hemodialysis access management comprised of a significant portion of the pie which cannot be neglected. A good vascular access is the premise of successful everyday renal replacement treatment and provides the possibility of up to the quality dialysis care.
With the progress of interventional technique and development of related medical devices, the treatment for dysfunctional dialysis access had evolved a lot in recent years from traditional open surgery to minimal invasive vascular intervention. As an interventional nephrologist, one should be familiar with handling of the clinical problems regarding vascular access in a less invasive way, i.e., vascular intervention. Here are the advices from a senior access surgeon.
The goal of performing interventions on dialysis access is to correct the failing access and make it functional again with the minimal cost of intervention. One of the basic issue one has to take into consideration is the quality of life of our patients. We perform the interventions by ourself instead of sending our patients to someone else (vascular surgeons or other interventionists) because that we believe in the concept of minimal invasive vascular intervention can benefit our patients and the fact that we interventional nephrologists can perform the procedure well with minimal cost to our clients.
Bear in mind all the time that “minimal invasiveness” is the gold standard when we performing any kind of procedures. As a physician, we want to benefit our patients under the condition of “doing no harm”. However, even for a modern interventionist/surgeon, it’s rather impossible to gain the access to human vascular system and fix the lesion without creating any wound or bleedings. Thus, minimizing the invasiveness of the procedures are our responsibility. We believe that under many circumstances, vascular intervention is better than traditional open surgery regarding fixing the dialysis access related problems in terms of minimizing the complications and improving the life quality.
As an interventionist, please be passionate of the term “minimally invasive”. We have trained ourself to perform the treatment well and have strong belief in our weapon. Believe in what you have learnt during your clinical practice and design every time a minimally invasive way of treatment for your patients’ dialysis access problem.
Learn fundamental stuff
Vascular intervention for dialysis access is a kind of technology regarding treatment of the lesions in the setting of diagnostic angiography and interventional radiology. It may be either performed in a ceiling-mounted fixed angiography room or an operation room with a mobile C-arm unit. Trainings regarding interventional radiology has never been a must as a part of the nephrologist training. However, there are several fundamental things that an interventional nephrologist should be aware of and take care of before jump into the clinical treatment.
Some basic knowledge regarding dialysis intervention such as radiation safety, sterile technique, contrast agents, and different kinds of interventional weapons (wires, catheters, balloons, stents…etc.) cannot be neglected. In addition, a nephrologist should also learn the knowledge of access creation/revision and access monitoring/surveillance. Being familiar with clinical guidelines regarding dialysis access interventions is also important.
The knowledge on medical care for dialysis patients had accumulated fast and grown exponentially in the past decades. In this ever-changing world, the technique of intervention had changed rather fast with time. With the help from medical device manufactures, many new interventional equipments being made available on the market every year. These new gadget provides dialysis access interventionists the possibilities of revising and improving of our clinical patient treatment.
Be sure of getting constant updates of knowledge/techniques regarding dialysis intervention from various sources. Peer-review journals, annual academic scientific gatherings held by related medical societies, international symposiums on endovascular therapies held by different specialties (interventionist, angiologists or surgeons) are all valuable sources of knowledge updating.
Practice, practice, practice
Hemodialysis access management is a part of interventional nephrologist daily clinical work. From the view point of a access surgeon as me, constant practice is one of the basic requirements to make a vascular access interventionist a component operator. In our institution, our surgical fellows are required to assist or perform at least a thousand vascular access intervention procedures during their two years of training as a vascular surgical fellow before they are qualified to be an independent surgeon.
An intervention procedure can never be perfect. However, practice makes our procedures move toward perfection. Through constant practice, interventionist are able to improve their workflow and thus decrease their operation time , which means less exposure under radiation and less stress for our patients. Interventionists can also gain valuable experiences from different clinical scenarios and keep on improving the procedures toward the direction of minimal invasiveness and zero complications.
Patient care is something regarding teamwork. Although nephrologists adopt the interventional techniques and try to complete their capability of clinical care for dialysis access, it is still impossible for nephrologists alone to provide a total care for patients’ dialysis access. Creation of permanent access are still a surgical task for most of the dialysis patients. In addition, an interventionists always need a surgical back-up available to ensure the safety of our patients. Keep good relationship with your surgeon colleagues and establish flawless communications with them regarding issues on the care of vascular access whenever needed.
Hemodialysis therapy are usually performed 3 times a week. And dysfunction of access may happen any day during the week. To ensure the availability of quality access intervention whenever it is needed, establishment of an vascular access intervention team comprised of several interventionists (at least 2 to provide daily service), nurses be familiar with access interventions, and radiology technicians may be the way to do. The access intervention team should has its own angiography facility and be able to provide urgent service at least 6 days a week to cope with acute access disfunction cases. Thus an interventional nephrologist should also take the responsibility of spreading the concept and techniques of vascular access intervention in his unit and try to provide a more patient-friendly environment for the victims of renal dysfunction undergoing dialysis therapy. An institution without robust teamwork mechanism can never become a reliable medical service provider for patients with dialysis access problems.
5 tips to make aortic treatment less invasive:
1. Percutaneous approach for every case!
2. Minimal invasive anesthesia...no intubation!
3. Choose the right stentgraft!
4. Less is more
5. Team work
Our team had kept up with the tips and make our most of our elective aortic treatments office procedures.
(eBeing a vascular surgeon nowadays, it is imperative to learn to be an endovascualr surgeon. after all, minimal invasiveness is a must for modern doctors performing any kind of treatment.
How to become a competent endovascular surgeon/ interventinist?
1. Believe in endovascular therapy
Passion is the fundamental element of being a competent Endovascular surgeon. Passion is everything. You have to from the start believe that endovascular therapy is the right way to do. Most of us have been trained well in open/traditional techniques to solve the clinical problems. However, when you are facing vascular problems nowadays, please do not stick only to the traditional way of treatment. Think over and over again the advantages of endovascular treatment in contrast to traditional cut and shooters, you would then be confident in what you're doing.
2. Be open minded
Always be humble. Interventionists are not almighty. We cannot really cure diseases, we help. We are merely doing what we can to improve our patients' quality of life and make them happier. So, stay hungry and foolish. Be ready to listen to the ones who need our help.
Endovascular therapy is an art of interaction. Be sure to know the culprit lesion then decide the best/suitable intervention policy. It's not only about giving treatment, it's about communication with the heart of caring.
3. Update! update! update!
in this ever hanging world, the rationale, technique and devices evolve so fast that you may miss the catching-up-with easily. With the passion for Endovascular surgery, an Endovasculat surgeon should keep on updating his knowledge on the treatment not only because of his own curiosity but also for the calling deep in his mind. Make sure to read the latest informations, attend up-to-date symposiums and take part in every events (ex. vascular attachment program in CGMH) which may refresh and energize surgeons' concept and technique of patient care.
4. Find your mentor
Surgeons learn a lot from clinical practice. And during the practice, we want to minimize the complications as possible. Find a good clinical interventionist as your Endovascular mentor. Try to copy his procedures to treat your patients at your infant stage of clinical practice. Senior staffs' back up are always your patients' safety net. Learn the concept, attitude, technique, and knowledge from your role model in Endovasculat society. And thus the learning curve will be overcome within the shortest period of time.
5. Team work
Commending a modern endovascular therapy is like flying a jumbo jet. It takes a good teamwork two make sure that the procedure doesn't go wrong. Multidisciplinary professionals can guarantee to provide the best up-to-date technique in each steps during the whole procedure. Good preoperative study, and comprehensive preprocedure planning, Clea operation image acquisition, dedicate intervention technique, and available surgical bail-outs and back-ups are the keys to the success of modern endovascular procedures. The concept of team work can never be too important for anybody who wants to become a competent endovascular surgeon.
Dialysis graft outelt stricture is one of the most frequent complication/situation that a dialysis surgeon faces in his dailiy practice. To cope with the stenotic lesion, the oldest way, probably the most reliable, is to do surgical revision.
There are two ways of surgical revision of the graft outlet. Here shows the so called" patch angioplasty" method. If the stenotic lesion is a focal or short lesion, we can just longitudinally incise teh graft outlet, and apply a ePTFE patch (which is the same material of the graft) to augment the outelt space. after the operation, the graft outlet should be widely open.
The operation usually takes around 1 hour to perform. ofcourse, reoperation sometimes will be troublesome. However, most of the stenotic lesion can be fixed by patch angioplasty. Only if the lesion is too long, then we will try to fix the lesion using a jump graft.
Ofcourse nowadays most of the graft outelt stenotic lesion are first treated with angioplasty balloons/ stenting, which is less invasive. However, surgeon should always keep himself familiar with the open procedure. and once the PTA doesnt work, we still can provide a feasible choice of treatment instead of giving up the graft!
A patietn of ESRD on regular dialysis vie her left upper arm graft. graft outlet segmental stricture was noted and the stenosis was refratory to repeated PTA (percutaneous balloon angioplasty).
During the venography study, graft outelt segmental stricture was noted. Due to the elasticity of the stricture, definite treatment is needed.
Definite repair of the outlet stricture was needed. The options were:
1. Surgical revision, which is more invasive and time consuming. In addition, the lesion extended up to the high axillary vein make the revision more difficult. General anesthesia was needed to do the jump graft revision which will add on more anesthesia risk.
2. PTA with stent insertion. Covered-stent insertion over the stricture segment can prohibit immediate recoil and may prevent recurrent stricture in the long run. In addition, it's only a percutaneous procedure which is low risk to the patient. Thus we had proceed with covered-stent implantation to deal with the graft outlet recurrent stricture.