Dialysis catheters are dual lumen catheters that are inserted through the skin into a vein with the tip located in or near the heart. These catheters are considered a temporary dialysis option for patients that do not have a more permanent option, such as a peritoneal dialysis catheter, a fistula, or a graft. The catheters allow rapid removal of blood to the dialysis machine through one of the two lumens and rapid return of the blood to the patient from the machine through the other lumen. Dialysis catheters can be placed temporarily directly into the vein, but these catheters are typically only used on a very short-term basis, such as during a hospitalization. More commonly these catheters are tunneled under the skin for a short distance before entering the vein. Tunneling a catheter under the skin provides greater patient comfort, prevents infection, and secures the catheter for longer term use. The catheters can be placed in a variety of locations, including the neck, chest, legs, and trunk, but the neck and chest are the most common sites.

During the procedure, a catheter placement will typically take less than a half hour. You will lie flat on the procedure table with your neck and chest prepared in a sterile manner. Surgical drapes are placed around the access site. If desired, you can receive a sedative through an IV line placed in the hand or arm. Dr. Kahn uses an ultrasound machine to locate the vein that will be used and anesthetizes the overlying skin with a local anesthetic. Dr. Kahn then makes a small incision at the base of the neck or chest before inserting a needle under ultrasound guidance into the vein. Once in the vein, a wire is threaded into the vein through the needle and the needle is subsequently removed.

Additional local anesthetic is administered along the planned tract of the catheter under the skin and a separate small incision is made at the anticipated catheter exit site. The catheter is then threaded under the skin from the exit site to the vein access site. Through a special type of sheath, the catheter is then

threaded into the vein and live X-Ray guidance is used to confirm the catheter position. The catheter is tested and then secured with a stitch to the skin. The catheter will be ready for immediate use.

During the recovery, you will be moved to a recovery room to be monitored by our nurse. Typically, the recovery period is brief and patients can be discharged home shortly after the procedure. It is normal for you to experience some discomfort after the procedure that is typically relieved by over-the-counter medication. Swelling or bruising at the site of the catheter may occur. Strenuous activity or heavy lifting is discouraged for several days after the procedure.

Peritoneal dialysis is an alternative to hemodialysis and is preferable to some patients, as it can be done easily at home. A peritoneal dialysis catheter is placed in the abdomen, below or to the left or right of the navel. This procedure typically takes less than an hour, and you will likely be able to leave shortly thereafter. Your abdomen and pelvis will be inspected before the procedure. Measurements for the planned catheter placement are obtained and marked on your skin.

Prior to the procedure, you will be transferred to the procedure room where you will lie flat on the exam table. Sedative drugs are administered, your abdomen is then sterilized, and a local anesthetic is administered at the planned catheter placement site.

After administering the local anesthetic, a small incision is made in the abdomen. Ultrasound and live X-Ray guidance are then used to advance a small needle into the abdominal cavity. Contrast dye is injected through the needle under live X-Ray to confirm the needle is properly located in the abdominal cavity. After confirming needle position, roughly a half liter of saline is infused into the abdominal cavity to facilitate easy placement of the catheter.

A wire is then guided through the needle into the abdomen. Once the wire is in place, the needle is removed. A dilator and peel-away-sheath are inserted over the guidewire into the abdominal cavity. When the sheath is in place, the dilator and wire are removed and the catheter is placed through the sheath. The sheath is removed and live X-Ray is used to confirm that the catheter tip is in the lower pelvis. The catheter position is important to optimize fluid administration and drainage from the most dependent portion of the abdominal cavity. The catheter is tested with the injection of saline and contrast dye to confirm its function and position. Once confirmed, the other end of the catheter is then threaded under the skin to a separate small incision made in the skin at the catheter exit site. The original small incision is stitched closed and the catheter is secured with a sterile dressing at its exit site.

During the recovery, you will be moved to the recovery area and monitored. You may experience minor discomfort that is usually managed with over-the-counter medications. Heavy lifting or strenuous activities are discouraged after the procedure. Care of the catheter is particularly important to prevent infection. Use of the catheter is discouraged for at least a couple of weeks after placement. Additionally, patients are instructed to follow up with the dialysis center within one week of catheter placement for testing and dressing changes.

Blood clots that develop in a dialysis access need to be treated to restore blood flow through the access. A combination of instruments and clot dissolving drugs are used to remove the clot and restore blood flow. Clot dissolving drugs are delivered directly to the clot and allowed to saturate the clot thereby dissolving it.

In addition, balloons and several mechanical devices are available to further break-up and remove the blood clot from the fistula or graft. As with all fistulagram procedures, you will be given a local anesthetic to numb the area and a moderate sedative is given to help you relax.

Steal Syndrome may develop in some patients who have a fistula or graft. This syndrome is characterized by insufficient blood flow to the hand caused byexcessive diversion of blood flow to the fistula or graft. The hand thereby receives inadequate blood flow. Symptoms of steal syndrome include pain, coldness, numbness, or tingling in the hand and patients may notice a pale hand color. In severe cases, wounds or tissue loss can occur in the fingers and hands. if you experience any of these symptoms, it is important to speak to your physician immediately. There are minimally invasive procedures that can be used to treat steal syndrome.

Minimally Invasive Limited Ligation Endoluminal-assisted Revision (AKA The Miller Procedure) is used to balance blood flow through a dialysis access so that there is adequate circulation to the hand. The access is adjusted to the proper size by using an angioplasty balloon as a sizing dowel and banding the access to the measured size. During the recovery, you may be prescribed some pain medication to help with any discomfort, but you should be able to return to daily activities within 24 hours.

What are the Benefits of Minimally Invasive Treatments of a Dysfunctional Access?

Treating a dysfunctional access with minimally invasive procedures to correct blood flow offers several benefits:

• Avoids the need for general anesthesia and the associated risks
• Quick return to daily activities
• Resume or continue your scheduled dialysis treatments without interruption
• Decreased procedural risks, including infection
• Safely performed as an outpatient, without the need for hospitalization