Michigan Vascular AccessFocusing on Fistulas andVascularAccessSolutionsforSoutheastMichigan

With monthly discussions on strategies for meeting the DOQI benchmarks for Fistulas and Topics in Endovascular Management of Dialysis Access NEWSNEWS

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CC OO NN TT EE NN TT SSMichigan Vascular Access PracticeNews:• New Staff Member• Ultrasound-Assisted Digital

Photo Mapping• The Lobster Club• Michigan Vascular Access

News and the “Fistula of theMonth”

• Office Location and ContactNumbers

Page 1

Achieving the DOQI Benchmark forFistulas in Hemodialysis: "Ultrasound-Assisted Digital Photo Diagramming of Problem Fistulas"Page 2

Endovascular Topics: MonitoringDialysis Access — Why, what, how andthen what?

Warning Signs for Grafts andFistulasPage 3

Maps and Contact Information forMichigan Vascular Access, PCPage 4

Fistula of the Month:“Ultrasound-Assisted Digital PhotoDiagram of a Problem Fistula”Color Insert

VOL. 2 No. 1 J anuary 2005 Editor: Marc Webb, MD, FACS

PRACTICE NEWSNew Staff Member

Ultrasound-Assisted DigitalPhoto Mapping

Since moving into our new offices inSouthfield in October we have re-emphasized our program ofultrasound-assisted digital photomapping (see lead article this monthand “Fistula of the Month”). Dialysispersonnel and patients struggling withfistulas difficult to access may benefitfrom these diagrams that show wherethe fistula is and how it runs under theskin. By appointment during office hours.

Michigan Vascular AccessNews and the "Fistula of theMonth"

"The Fistula of the Month" insert toMichigan Vascular Access is intended tobe an educational example of what ispossible in fistula creation, and isalways used with permission. We senda gift certificate to Red Lobster toreward and recognize those patientswho generously allow their pictures tobe used. If you have an outstanding

The Lobster Club

example of a fistula and would like tobecome a member of The Lobster Club,please send your picture (digitalpreferred) and a signed release for useto Michigan Vascular Access.

Stacy Lowes joined Michigan VascularAccess in December. Stacy bringsexperience with dialysis care from herprevious position as a hemodialysistechnician. In her new role as oursecond full-time Patient CareCoordinator she will be working withLucretia High to streamline service tothe dialysis patient and improvecommunications with other providers.

A monthly newsletter has proven to bedifficult to maintain. The MichiganVascular Access News will continue tobe produced on an every other orevery third month basis.

The "Fistula of the Month" will besent monthly, either as a part of thenewsletter, or separately.

Office Location and ContactNumbers

Our new office in Southfield providesa full-time home for Michigan VascularAccess. The new location is centrallylocated in the Metro area, and easilyaccessible from most area freewaysbeing located halfway between I-75and 275 on I-696, within a mile of theLodge and Southfield Freeways andTelegraph Avenue (see map on insert).The office is in the Beacon SquareOffice Building, Suite #4, 21701 ElevenMile Road, Southfield, MI 48076, 248-355-1100 office, 248-355-2717 fax. For amap and printed directions, callMichigan Vascular Access.

INSTALLMENT SEVEN

"Ultrasound-assisted digitalphoto diagramming of problemfistulas"

After an arteriovenous fistula iscreated, it must "mature,” and when itis judged mature it is released for use.For many patients, this begins adifficult period in which the dialysispersonnel "learn" the fistula. Duringthis process the patient may experienceinfiltration, difficult cannulation andfrustration. After a number of difficultcannulations it is not uncommon forthe dialysis personnel to fall back ontoreliance on the catheter, or to tell thepatient "This fistula is no good.” Wefrequently get a call to replace adifficult fistula with a graft when thedialysis personnel have had too muchtrouble. For us to say that the dialysispersonnel don't know what they aredoing is not helpful, and ignores thefact that we are all trying to worktogether for the benefit of the patient.

In fact, may fistulas do not developwell enough to be used for dialysis. In

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EFFECTIVE STRATEGIES FOR IMPROVEMENT INVASCULAR ACCESS

1. Ultrasound mapping in the surgical clinic and operating room.

2. Looking beyond the dominant arm for secondary fistulas and to find the bestvessels.

3. Using a wider variety of fistulas than just wrist and elbow fistulas.

4. Breaking the rules and challenging the usual limitations.

5. Monitoring development of new fistulas and techniques in fistulatransposition.

6. Converting grafts to fistulas and converting worn-out fistulas to betterfistulas.

7. Digital photo mapping of fistulas to aid dialysis personnel.

8. Monitoring of access to detect dysfunction, guide intervention and preventloss.

9. Effective surgical and endovascular interventions in the failing fistula.

10. Creation of a coordinated program for vascular access care.

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Achieving the DOQI Benchmark for Fistulas in Hemodialysis:Strategies for 2005

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my practice, I generally quote a 75 to80% chance of a fistula developing tothe point of being usable. Somesituations are more positive, and I havegiven up to a 95% probability (never100%), and have offered other, moremarginal patients, a 50-50 chance ofdeveloping a fistula if the situationwarrants. However, if the surgeon feelsthat a fistula has "matured,” it shouldbe usable. Failure to successfully usethe fistula may mean that the surgeon'sjudgment is off, or that additionalguidance is needed.

The ultrasound-assisted digitalphoto diagram can be part of the"users manual" of a fistula, and canhelp the "user" (dialysis personnel) touse the fistula successfully. Cars comewith user manuals, computers comewith user manuals, and even toasterovens come with instructions anddiagrams. A life-sustaining vascularaccess for hemodialysis is no lessimportant.

In our clinic, a digital photographof the patient's arm is taken andprinted immediately on glossy photopaper. The visible landmarks

(operative scars, the elbow crease, etc)on the patient's arm are then labeledon the picture. Using ultrasound, thefistula is drawn on the picture, withdepth, width, branches if present andcourse marked. Areas to cannulate andareas to avoid are indicated. Theexpectation is that with a betterunderstanding of the fistula,cannulation will be easier for thedialysis personnel, and easier for thepatient.

The ultrasound-assisted digitalphoto diagram does not solve allproblems. Some fistulas are too deep,some fistulas require operative orendovascular intervention, somefistulas will never be big enough tocannulate, and some fistulas haveinsufficient flow from inflow arteriesthat are just too small. But, a fistulathat is converted from a frustratingproblem access to a reliable asset aftera simple office procedure is a save.

Ultrasound-assisted digital photodiagramming is provided by appointmentduring office hours at Michigan VascularAccess.

"ACHIEVING THE DOQIBENCHMARK FOR FISTULAS IN

HEMODIALYSIS — STRATEGIES

FOR 2005"is a one-hour presentation of 18strategies and a demonstrationof practical surgical techniquesto increase the number offistulas created, matured,successfully cannulated andmaintained over time. Surgicalexamples are drawn from theauthor's full-time vascularaccess practice.

For an advance presentation ofthis talk, contact MichiganVascular Access at 248.335.1100.

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Endovascular Topics: Fifth in a Series

To be added to the mailing list for

Michigan Vascular Access News,simply send your

name and address to:

MV MVA NewsA News

MichVascAccess@aol.com orBeacon Square Office Building

21701 W. Eleven Mile Road, Suite #4Southfield, MI 48076

248.355.1100

Monitoring Dialysis Access —Why, what, how and thenwhat?

All of us have important investmentsin our lives — homes, automobiles,careers, relationships — whose losswould be a serious blow. To preventthese losses we periodically check upon our investments, and whennecessary, re-invest in maintenance,repair or improvements. We monitorthe oil and coolant levels in our autos,we keep smoke and monoxide detectorsin our houses, we seek performancefeedback and mentoring at work, andwe pay attention to our loved ones. Ifsomething is off, if there is a warningsignal anywhere, we act promptly witha back rub, flowers, and a dinner out toprevent loss of an importantinvestment.

Vascular access for dialysis is oftenonly achieved with patient sacrifice andeffort. It is not easy to undergo severalprocedures before a long-term access isachieved, and a well-functioningdialysis access is an investment worthprotecting. Unfortunately, like Englishand Italian sports cars, dialysis accessescan be fickle and tend to break downfrequently.

All "permanent" dialysis accessesare prone to failure, and require anoccasional "tune-up" or completeoverhaul to keep them functioningproperly. It is estimated that dialysispatients require between 1 ½ to 2procedures a year to keep their accessesfunctioning well. We estimate that 85%of graft and fistula failures are relatedto correctable narrowings in the access,and that thrombotic events arepredictable, treatable and hencepreventable. We do not want toprocrastinate and end up with a clottedaccess, a disrupted schedule and anemergency surgery. It is far better totake care of things electively. On the

other hand, because maintenanceprocedures for dialysis access areinvasive (poking, cutting and stitching),and because they are expensive, wewould prefer to make sure we are onlydoing what is necessary. We need someguidance on when to act.

In previous issues we haveincluded "Warning Signs for grafts andfistulas", which represent the problemsigns that patients' and their familiescan watch for. We have many patientswho are attuned to their accessperformance, and call us directly whenthey see their access failing. They do notwant to find themselves on the side ofthe road waiting for the tow truck.

Anyone who can lay their hand onthe patient's arm can make anassessment of dialysis access function— the patient, the family member,dialysis technician or nurse,nephrologist, radiologist or surgeon —and many of the patients with problemaccesses are referred for a correctiveprocedure based on these abnormalphysical findings (the "Warning Signsfor Grafts and Fistulas").

More scientific assessments areavailable however, and may moreaccurately determine which patients areat elevated risk of thrombosis. Elevatedvenous return pressures indicatevenous outflow resistance usually dueto outflow stenosis. Static venouspressures in the venous end of the graftover 50% of mean systolic pressures arecorrelated with a quadrupled risk ofgraft thrombosis in the near future.Identifying these patients and referringthem for an elective correctiveprocedure keeps the patient on the roadand out of emergency situations.Intervention with percutaneoustransluminal balloon angioplasty orsurgical revision dramatically reducesthe thrombosis rates and, in some cases,increases graft longevity (Besarab,"Preemptive Access Monitoring and

Surveillance", Vascular Access forHemodialysis VIII, Palm Springs 2002)

By most accounts, the mostsensitive measure of hemodialysisfunction is access blood flow. Flow ratesof less than 600 ml per minute arecorrelated with a doubled risk of accessthrombosis. Declining rates of bloodflow are also. The National KidneyFoundation's Dialysis OutcomesQuality Initiative (DOQI)recommendation in 1997 was thatmonthly measurements of blood flowshould be done, and thisrecommendation has been proven to bereasonable. Monthly monitoring ofaccess flow, coupled with referral forpre-emptive correction, has been shownto reduce days spent in the hospital,missed dialysis treatments, and catheterusage, as well as overall costs by 50%.Unfortunately, few dialysis centers haveinvested in this technology.

Whatever the method of assessingthe ongoing status of a dialysis access,an important truth is that all"permanent" dialysis accesses are proneto failure, and require an occasional"tune-up" or complete overhaul to keepthem functioning properly, just as aYugo, Chevy or Mercedes requiremaintenance. Failure to follow asensible maintenance schedule makesus vulnerable for a breakdown, andexposes us to possible loss of thisimportant investment.

F To arrange the declotting of a graft orfistula, please contact MichiganVascular Access.

F To arrange a presentation of"Endovascular Management ofHemodialysis Access", orThrombolysis of Dialysis AccessConduits," contact Michigan VascularAccess.

WARNING SIGNS FOR GRAFTS AND FISTULAS

• Prolonged bleeding from access after dialysis — over 20 minutes.• Change from a "buzz" or vibration felt over the graft or fistula to a pounding pulse.• More than one episode of infiltration or bruising around the graft or fistula.• Poor dialysis (insufficient clearance, recirculation) due to low flows.• A trend toward decreasing blood flows in a graft or fistula.• Elevated venous pressures on dialysis.• Swelling of the hand or arm on the side of the graft or fistula.• Development of "new veins" or popping out of old veins.• Pain in the graft or fistula.• Swellings in the graft or fistula.

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Michigan VascularAccess, PC

Focusing on Fistulas and Vascular Access Solutions for Southeast Michigan

CONTACT INFORMATION

BEACON SQUARE OFFICE BUILDING

21701 W. ELEVEN MILE ROAD, SUITE #4SOUTHFIELD, MI 48076

SCHEDULING & MESSAGES: 248.355.1100FAX: 248.355.2717

E-MAIL: MICHVASCACCESS@AOL.COM

LUCRETIA HIGH, COORDINATOR

CELL PHONE/VOICEMAIL: 248.890.0468

STACEY LOWES, COORDINATOR

CELL PHONE/VOICEMAIL: 734.890.2622

HOURS

MONDAY - FRIDAY

8:00 AM - 5:00 PM

CLINICAL APPOINTMENTS

MONDAY, TUESDAY & FRIDAY

8:30 AM - 12:00 NOON

Bon Secours Hospital

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Clarkston

Andersonville

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Highland

Pontiac Lake Rd.

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Union Lake

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Drive

Elizabeth Lake Rd.

W. Huron

Commerce

Cooley Lake

Auburn

South Boulevard

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MontcalmN. OaklandBlvd.

East B

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North OaklandMedical Center

North Oakland Medical Center

Bon Secours468 Cadieux Road

Grosse Pointe, Michigan 48230313.343.1000

North Oakland Medical Center461 W. Huron Street

Pontiac, MI 48341-9906248.857.7200

Providence Hospital16001 West Nine Mile Road

Southfield, MI 48075234.849.3000

St. Mary’s Hospital36475 Five Mile Road

Livonia, Michigan 48154734.655.4800

William Beaumont Hospital3601 West 13 Mile Road

Royal Oak, MI 48072248.898.5000

HOSPITALS

St. Mary’s Hospital Marian Professional Building

William

Beaumont

Hospital

Royal Oak

MICHIGAN VASCULAR ACCESS OFFICE21701 W. 11 MILE ROAD, SUITE 4SOUTHFIELD, MI248.355.1100

NORTHWESTERN HWY.

NORTHWESTERN HWY.

NORTHWESTERN HWY.

10696

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WALTER P. REUTHER FWY. W. 11 MILE RD.W. 11 MILE RD.

JOHN C. LODGE FWY.

Providence Hospital

Michigan Vascular Access Office