For someone experiencing kidney failure, dialysis is a lifesaver. Until very recently, open surgery was the only method available for creating the preferred dialysis access, an arteriovenous fistula.
Dr. Allison Tan, an interventional radiologist at Thomas Jefferson University Hospital, is changing the future for kidney failure patients with a procedure called endovascular arteriovenous fistula (endoAVF) creation. She is the first physician in the Philadelphia region to perform this procedure using the FDA approved WavelinQTM endoAVF system.
Dr. Tan answered questions about her experience with endoAVF creation and discusses how she feels it will impact the dialysis community.
Can you describe the endoAVF procedure?
The endoAVF procedure is a minimally invasive way of creating a hemodialysis fistula. Under twilight sedation, the artery and vein in the arm are accessed with a small needle and tube through which the device is introduced. Tiny magnets on the device align, bringing the target artery and vein together. An energy pulse lasting less than one second creates a channel between the artery and vein, known as a fistula. The device and small tubes in the blood vessels are then removed.
Patients go home the same day and will see only two pinpoint marks on the arm where the blood vessels were accessed. The main restriction after the procedure is to avoid heavy lifting with the arm for four weeks, after which patients can resume their normal activities.
What patients are candidates for endoAVF creation?
This procedure is an option for patients who are either planning to initiate dialysis or are already requiring dialysis. It is important that the blood vessels in the chest and upper arm have not been disrupted by prior surgery. Arm vessel anatomy is assessed at the time of an initial clinic visit using noninvasive ultrasound imaging. This ultrasound provides the necessary information needed to counsel patients about all of their dialysis access options.
When can an endoAVF be used for dialysis?
EndoAVFs are typically ready for dialysis use about four to six weeks after the procedure, similar to those created with open surgery. An ultrasound examination performed two weeks and four weeks after the procedure will assess fistula readiness. As with all fistulas, either endovascular or open surgical, some may require an additional minor procedure to prepare it for dialysis use. Studies indicate that these additional procedures are only needed about half as often after endoAVF creation than after open surgical creation.
Why do you think endoAVF creation is such an important advancement for dialysis patients?
At this time it is not possible to provide kidney transplants to all who need them, and dialysis is the only life-saving alternative we have. Since the first open surgery to create a dialysis fistula was described in the 1960s, there have been no major advancements in how we perform this procedure until now. The minimally invasive endoAVF procedure is the first time we have been able to create a dialysis fistula through only a tiny needle stick on the arm with comparably excellent results.
Additionally, we know that the survival of patients with kidney failure depends on maintaining dialysis access. A number of fistulas, endovascular or open surgical, will either never work or stop working over the course of time and additional access sites will need to be created.
EndoAVF creation is groundbreaking in that the fistula is created in a new location in the arm, not already utilized for open surgery, and does not rule out future surgery if needed. Therefore, this procedure is not a replacement for but instead a complement to open surgical fistula creation. By adding endoAVF creation to a patient’s options, we are increasing the number of potential dialysis access creation sites and helping patients with kidney failure live longer lives.