Dialysis access intervention: a hidden gem

Created - 07.08.2016

Dialysis access intervention is one of the most challenging and yet rewarding areas in Interventional Radiology.

Fistulas and AV Grafts are by their very nature unreliable. A vein, with 20mls/min of blood passing through it, has to accommodate up to 2000mls/min once a fistula is formed. It is perhaps not surprising that these high volumes, turbulence and sheer stresses lead to stenoses, worsening dialysis and a trip to IR theatres. In maintaining these lifelines we make a huge impact on patient’s lives, enabling ongoing dialysis without the need to resort to central venous catheters with their well-documented morbidity, and negative impact on survival. Salvage of an occluded access is equally important, and the impact of dialysis access intervention is never greater than when a fistula thromboses. Thrombectomies, approached with determination and given due time, have an 80-90% success rate. As well as standard fistuloplasty and thrombectomy, central venous intervention in patients with symptomatic stenoses can be challenging and time consuming but has the potential to significantly improve quality of life and dialysis adequacy.

Dialysis access intervention is both clinically rewarding and rich with opportunity for research and creation of national registries to guide best practice. For example, drug eluting balloons (DEBs) in fistuloplasty have great potential for reduction of neointimal hyperplasia and consequent stenosis but there is a paucity of evidence to date. Two UK multicentre RCTs are now recruiting (PAVE and DEVA) with the data keenly awaited. Industry is already investing in this field, manufacturing larger diameter, higher pressure DEBs suited to fistula use in anticipation of positive outcomes. The treatment of central venous stenosis is another opportunity for research and development, with the role of stent-grafts and novel devices such as the graft/ catheter hybrid (HeRO) device yet to be fully determined.

The Vascular Access Society of Britain and Ireland (VASBI) was formed five years ago and has grown considerably in this relatively short period of time. VASBI is a multidisciplinary group consisting of IRs, nephrologists, surgeons and specialist nurses with the aim of sharing practice ideas and improving dialysis access care in the UK. In addition, VASBI promotes education and research through study days and registries. The annual conference occurs every September with over 150 delegates and presents an opportunity for IRs around the UK to further understand and promote this vital and rewarding area of interventional radiology. 

Pete Littler Consultant Interventional Radiologist, Freeman Hospital, Newcastle upon Tyne Rob Jones Consultant Interventional Radiologist, QE Hospital, Birmingham