Fistula and Graft Placement (Eric K. Peden, MD)

so yeah fishel engraft placement this is

it is a challenge the thing charles

going to talk about with management of

steel i think it's really important for

later i would say kind of my my things

from this are when fistula first came

out is right around the time that i was

in training and that had finished and

there was a great educational program

that came out with that was hugely

influential in terms of how dialysis is

done in this country there's great

educational things on that they're

dedicated dialysis meetings where people

go and that's all they talk about i

think some of those are really

phenomenal in terms of increasing your

knowledge and awareness and thinking

process around dialysis really important

for me if i'm a one-trick pony and i

honest is a ton of what i do

it's ultrasound ultrasound old town old

town and probably some or old soon and i

use ultrasound in the clinic right so

we've got a vascular lab the ladies back

here they do the routine mapping and

such but even so the ultrasound in my

hand incredibly powerful tool right

patient doesn't listen hit him on the

head with it

patient's got no veins look at her arm

with it fellas talking up hit them in

the head with it you know whatever but

but ultrasound in your hands before

surgery during your planning of surgery

at the time looking at them after

surgery it's just incredibly helpful I'd

much rather go in without my stethoscope

or white coat or maybe my pants then

without the ultrasound because I don't

you sound just so incredibly helpful in

terms of planning how you're gonna do

your stuff and then helping you evaluate

what the problems are etc so for graph

specialist all of it what's our goal our

goal is to make Mittal's talk obsolete

we don't need catheters right we'll get

people off of catheters right because

catheters are bad but it needs to be

easy access right just because it's got

a great thrill and you're proud of it

and two liters a minute are going

through of it and that kind of stuff

doesn't mean it can be used for dialysis

so it's got to be accessible

hopefully it's durable right because

sadly the transplant lists are going up

and up and up and right now the wait

time here in Houston is five years you

go sign up for a kidney and you're

waiting on this it's five years that's

that's a lot of fish to lose and graphs

potentially you're gonna have to burn

through during that requires little

maintenance last governing evolving

thing right now there's a financial

incentive for access centers etc to be

doing routine

angioplasty histograms etc almost daily

on people it seems but in the future

that's not gonna be the case right

though the reimbursement for this is

going to change to the ACO model that

basically the Vita force in us whoever

gets X amount of dollars to take care of

dialysis needs and that's coming because

the expense of dialysis is just out of

control compared to the percentage of

patients that it actually is so least

painful that's really good least

disfiguring well I can't claim to be a

minimally invasive surgeon myself for

sure and I think if you need a bigger

incision you need it but hopefully some

of us not going to scar them up too

badly relatively complication-free

that's going to important to you and

your malpractice amounts that you have

to pay each year and then preserving the

next access option I think you know if

there's a few things you think about

it's each access is precious plan for

failure and don't screw your next option

because you want to be able to do

something when this if it goes down

because it because it almost certainly

will fail alright so simple direct

fistula is right rado smilax break

hispanics proximal radio artificial --is

transpositions we have to move the veins

around really helpful to have all these

things in your bag because you're not

gonna get to the dokey suggestions just

by gangway dispelling chrysalis it's not

gonna happen not not a few in an

environment like this where they're

sickly people that don't take a gear

themselves that have been in the

hospital much times have had a bunch of

IBS etcetera it's a radius felt like

this almost always drawn at the wrist I

will tell you I personally almost never

do it at the wrist again old sound old

sound and more ultrasound I follow it

down look from the antecube up and down

to try and figure out where the veins

are and I follow it down from those

pictures that he showed you is gonna go

in the upper arms phallic vein and the

basilic vein and the perforator vein and

follow it down until it's still good and

when it becomes not good or branches too

much and become small in my hands that

means three millimeters I want to see if

three millimeters are bigger and that's

where I'll make my incision not just

open the wrist when I was in general

surgery and did some of these we just

opened the wrist took a look but Sarah

hook it up it's not open the elbow take

a look buts the air hook it up if not

trying sewing a graft that didn't work

go to the upper arm make an incision

take a look I mean that's exactly the

way it was done really pathetic if they

all look like this every time this would

be like a really short talk you'd say

okay just make an incision like this on

everybody hook the veins up and look

like this it's perfect next lecture but

that's not the way they usually look

right then you know people are bigger

people are deeper hard to even see these

things right and they've got to be able

to see it and feel it and stick it for

it to be a useful fistula

brachiocephalic fishless this should be

the easiest fistula there is but I would

tell you and today is access environment

this is the Beast this is the Beast that

causes all the problems and this is

probably one of my least favorite

operations although it should be the

easiest because the Ivy's have always

been stuck in and at the ANA cube right

so it's usually stenotic about two

centimeters up above the incision so you

just can't quite reach it there but

hopefully you've seen that with

ultrasound right hopefully you've seen

that it looks small and thick there I

may be gonna plan your incision

differently so that's a problem then

we're deep dives into the deep system up

with the Yang's illa that's a real

problem and then causes steal that's the

problem this is the one that causes most

steal on contemporary series so although

it should be the easiest fistula to do

and I think it's pretty straightforward

because the vessels are bigger it's one

of the most problematic fish shows that

there is today and if it looks all

squiggly like this there's some kind of

problem that you're ultimately gonna

have to deal with later either high flow

or outflow obstruction etc this official

that I almost never do the guy who kind

of invented this and never retired so I

think that's probably gonna go away but

but sometimes if you work anywhere

around Oklahoma or anywhere that tip

jennings ever has talked you'll see

people that have some of these and it's

loops it's official from the proximal

radio artery so that it doesn't go off

the distal where it's small and

calcified doesn't come off the brachial

where you're more likely to have steel

and he does this side-to-side connection

and Lices the valves here so it kind of

pressurizes the whole venous system

there and can potentially give you more

access options and sites if your units

not used to dealing with this it's a

real headache and leads to lots of phone

calls because this drawing washes off

right the lady that's there on Monday is

not there on Wednesday so they have no

idea what to make the person with this

pistol in their arm which is a real

challenge form transpositions

part of my training was under Mike Silva

he actually got a code approved for this

and basically it's moving the vein

around and now listen I think this is

still the way they do even their radius

phallic fish hoses make a big incision

move the vein get all the branches away

and then plug them in the artery so you

have one single channel that's not the

way most of us would do

radius of Alex for most of us so we

would do this for basilic fistulas right

so mal showed that big beautiful vein on

the back of the arm so seeing that

making incisions over it tying off the

gazillion of branches I now use Clips

mostly for that and then tunneling it

over the front of the arm because nobody

likes to sit there like this during

dialysis getting their arm stuck and

holding it like that so the needles

don't move

I like making marks on the veins so they

won't twist tell it over the front and

again you get controlled the depth of

this since you're doing a tunnel make

sure it's nice and superficial because

sometimes it will be too deep and then

fuzzy picture and it all works out and

fortunately the arm is very tolerant of

long incisions and stuff you don't

usually have incisional break down the

arm like you do in the groin and and in

the lower extremity and stuff basilic

transpositions I think it's important to

do transpositions not just elevations

people don't like getting stuck on the

medial part of the arm it's more

sensitive more painful you're close to

the artery a deep plunging needle which

does happen can go down and your nerves

and the artery so you should really

transpose it and typically we do that in

stages where we'll make it and make an

incision now at the elbow somewhere

again as low as we can connect it wait a

month or so and then come back and

transpose it it's important to take

these branches of the medial

antebrachial taneous nerve away so if

they're not getting stuck almost always

at least in my hands and trying to

preserve all these I can people wind up

with numbness in the forearm setting

expectations crucial doesn't matter what

part of ASCO surgery you're talking

about there's failures sometimes lots of

them sometimes a few of them sometimes

really dramatic and tragic but letting

these people know ahead of time you're

gonna have some numbness in the form

that saves you about 20 minutes later

when you're saying no I promise you it's

standard it kind of happens all the time

I know I didn't tell you about it before

but it's happens all the time so now I

didn't catch your nerve and half I

promise it's routine it's not gonna

affect your hand I mean that

conversation gets really old in the end

so it's much already to have that in the

beginning and say you're gonna have

little numbness probably gonna get

better when they come back a number to

say remember I told you it's gonna get

better it's just give it time if it

doesn't hopefully four months down the

line and left your practice or something

but so I divide it completely between

first and second stages and re tunnel to

a superficial more lateral and again the

more Supra so the more lateral and the

more length of aim the better because

the more than you make it easy on the

dialysis you know more they're gonna

make it easy on you

torture you I don't typically do skip

incisions dr. Winn does and they look

beautiful I find it to be a real

struggle and wherever my tunnel is of

course is where the biggest deepest

perforator is I can't quite see and have

a hard time like getting etc so I

typically just do a big saber slash in

the arm and do it and you'd like to get

it more lateral than this right and this

sometimes you just run out of vein but

the more lateral you can get it the

better and again big arms it can be roll

challenge and these things can get

really big but it's not typically the

fish so that causes steal for whatever

reason even though it's bigger than this

phallic vein it's not the one that

typically causes the problems so any big

big long lines that can't have incisions

so I can't have aneurysms and it's

failure point tends to be where it goes

back down and dives in the deep paints

and make sure you really free that up

you can do upper arm cephalic

transpositions not my favorite thing to

do because sometimes this incision

doesn't heal so well especially in

biggest people but again knowing where

the vein is marking it for them

hopefully then spots get tattooed and

can see it and again really important to

let them know that the vein is not under

the incision otherwise they're just kind

of jabbing and stabbing or that is and I

make it drawing to send them all back

with this a person has had a brachial

transposition not one of my personal

favorite operations more tedious lots of

branches hard to get enough length but

can be a really good thing for youngest

people this is an immunosuppressed

person who had all kinds of graft

infections and can't can be good fishel

but not quite as good as the others and

that data would suggest it's not as good

as basilic sand if you put it up against

grafts I'd say it's it's an equal toss

this is one of the things that I think

is one of the more helpful operations to

do for people especially here in Texas

and in Houston where the food is so

awesome it's super visualization I call

it official elevation it's not it's a

light Peck to me I just don't like to

tell people I'm gonna tell you're fat I

say I'm gonna bring your fish stock but

if the fish Allah is deeper than it is

big right fish was deeper in it is big

then the proportions not right and

they're gonna be stabbing and jabbing

and torturing that person and then

torturing you and your office staff if

that's the way it goes because it'll be

really hard to hit so if it's deeper

than it is big then superficial eyes it

you can do it with big long incisions

like I showed at the beginning where you

make that

bring it up and retell it and this came

out a few years ago and GBS and

basically take this fan out so if the

skin is sitting right down on it it

makes all the difference in the world an

official that might have been just kind

of soso --is-- to use before now becomes

right there on the skin easy to feel

easy to see easy to stick and can make

hard fish listen to easy fish was for

the Dallas you know which really

hopefully should be your goal I would

say if your practice doesn't do this

look up the paper because this is a

really helpful thing to transverse

incisions make skin flash just like

you're done mastectomy then dissect for

the fistula so you don't injure it then

scoop out the fat you can usually get

quite a bit of fat out of there and then

close the thing up I like closing up

over a drain tipped innings the same guy

has talked about not closing with a

drain down a couple of stroma is when

I've tried that so I personally just

like using drains usually just stays

overnight and then go home the next day

let that heal for about a month and then

usually I get it's usable arm grafts I

think it's really important again that

each thing is a precious option don't do

just one type of graft because then

you're going to have one on each side

you can do and preserve your options

right really uncommon nowadays to do a

graph like this if people have a vein

here they're probably getting a fistula

so most people to get grafts these days

are they're elderly folks that you don't

think you're going to do a fistula in or

can't really benefit from that or people

that have had these superficial veins

exhausted so when I say don't use up the

real-estate don't just make your first

graph like this where it goes right from

just above the elbow to right up to the

armpit and then it's a big beautiful

graph that's true but in two years it's

done right now what you've already got

sting crafts are nothing like Zilla so

if I do an upper arm graft ultrasound

all sound and ultrasound again so I'll

come down to the middle of the arm

wherever I think the vein is big and

usually it's brachial vein I'm talking

about and make my incision there so kind

of a graft in the middle of the arm the

same thing in the in the leg when you're

making a thigh graft it doesn't have to

go to the groin it can go down in the

middle of the thigh over the arteries

and veins are good enough to accommodate

it so saving that so that you can march

up the limb later really helpful because

there are a lot of folks that don't get

transplants for whatever reason the late

time etc so criminal activity in this

arm I would say somebody's had a forearm


there's been lots of activity honestly

but somebody's had a farm graft and then

has it jumped across up into the basilic

vein above the arm above the elbow

that's terrible now you've taken out the

basilic vein fistula is an option for

the person so don't jump it up to there

and I'd say all of this this is just

vain that was sitting there waiting to

be used now it's like isolated from the

rest of the body right cuz because the

graft has gone way up high to the armpit

so all this vein that was in here is now

kind of wasted territory you can't go

back to any more because this is all

obstructed now

so making a graft in here saves you then

this is your next option the four years

on there Armistead just two years so

again don't jump across to the basilic

and don't go straight to the armpit when

you're in the upper arm leg


this can be kind of a make it into a big

surgery kind of thing which makes it fun

but and it's a little bit gory obviously

it's a it's a big vein right the femoral

vein is what we're talking about so not

superficial femoral vein at the femoral

vein it's a big vein saphenous veins

typically don't work well for fistula

because they don't grow because the wall

is too thick the femoral vein can be a

really nice official it's typically

already big enough it just needs to get

in somewhere and get sealed and healed

mobilize the full thing down to the knee

transpose it around I like to hook it up

to the mid SFA you can put it back to

the to the groin once they heal up it

works fairly nicely this is the fish'll

in here and this is a young woman with a

transplanted catheter and that's a bad

deal saphenous veins again don't work so

great tend to be thick and tend not to

grow again they're more grafts go to the

mid die save the groin for later groin

disasters or groin disasters whether

it's from a fem-pop or an AV graft you

don't want to turn your access more

complicated than it needs to be so stay

out of the groin if you can and then

it's kind of down the thigh it's easier

for them to see and feel you don't have

to make it so long to get away from the

grind to have it accessible they don't

have to pull their shorts up so high or

whatnot and again that makes it nice

staying away from the groin is always

good if you can so start simple work

your way up preserve your future options

absolutely key so simple direct

officials first transpositions versus

grafts later and then thermal access is

way down the line unless you have a

young person who doesn't have good

brickster me stuffing you like fish like

you don't typically do the other

sowho bits of US official is almost

everybody right graphs who should get a

graft it's not clear but probably the

elderly patients are gonna be better off

with graphs and fishless that that is

certainly swinging that way this was

that don't work are not as good as

graphs right

graphs are better than fishes that don't

work so plan for this was that you think

have a really good chance of working if

you're in sort of the the DAC criteria

where only forty percent of your

officials in maturing that's not good

enough you need to do better think about

the hero graph or patients with

exhausted options right for patients

with central venous obstruction the hero

graph can be really helpful essentially

just a graph that you can put in to

connect it through you'll probably do

some of these in your training really

helpful to have this new material for

patients with central venous occlusions

the hybrid graph good for people have

kind of wiped out their arm options that

you can basically stink graft up into a

patent area that you couldn't have

gotten to surgically this is way beyond

the axilla where they could decent

famous patients have already had stink

grafts so good to have some extra tools

on your hand okay that's everything you