University of Cincinnati Surgeon Response

Basicallly, in a nutshell, the University of Cincinnati surgeon said that the problem with the buttonhole process is that the Fistula is being stuck in the same place, over and over, time and again. U.C. surgeon is the one that fixes the problems with the access surgery, after the other surgeons have screwed up. If anyone needs an access, trust me, he is the best. I would be happy to give out his number. I was going to get a graft, but now, I am going to get a real fistula. The U.C. surgeon and my nephrologist fought it out and I am going to get the real thing, again. If you need a transplant, again, he is the best. The U.C. surgeon has been doing transplants for 40 years and my nephrologist has been practicing for 30 years. Both specialists are considered to be the best in the metro area(2.3 million) Hopefully, by the time, the fistula fails, the WAK belts will be ready. When those belts are ready, my specialists will be the happiest people on this earth.

Mark

Mark, this is exactly the point of the Buttonhole technique–cannulating in exactly the same spot, at exactly the same angle, over and over again. Done right (this means by the SAME person at the exact SAME angle–preferably the person with the fistula), this technique has been shown in research to cause fewer missed sticks and fewer aneurysms and bumps. The only problem that has been seen is a risk of infection if the scabs are not removed the right way. But infection is always a risk with any access, and good technique can prevent it.

Unfortunately, the Buttonhole technique is often done wrong:

  1. Staff insist on starting Buttonholes, because they don’t trust patients to use sharps, or they worry about liability. But clinics can rarely assign the same person to cannulate for as many treatments in a row are needed, so 2 or 3 or 4 different staff may try, each with a slightly different angle. This can lead to “coring” – making the hole larger and larger so blood leaks out around it during a treatment, and people say, “that Buttonhole thing doesn’t work, we tried it.” WRONG.
  2. Even if, by some miracle, you can get one staff person to start Buttonholes, it’s unlikely that he or she would cannulate at the same angle that YOU would. So, you’d end up with a Buttonhole that is awkward or difficult for you to use, or where the blunt needle just won’t go in the track. Then people say, “that Buttonhole thing doesn’t work. We tried it.” WRONG again.

I’m glad your doctors are so experienced, but sometimes doctors don’t keep up with what’s new (though the Buttonhole technique was actually first done about 30 years ago). Or, they don’t like change. If it were me on dialysis, I would absolutely use the Buttonhole technique. The data are persuasive, and so are the testimonies of people who use it the right way.

As far as the WAK, I suspect that SOME new machine (maybe not that one) will be on the market within 3 years or so, and there may be several within the next 5-6 years. Folks are going to have more choices relatively soon, I think!

http://healthnews.uc.edu/news/?/7651/

Major collaborators include Rino Munda, MD, and colleagues from the department of transplant surgery, as well as physicians and researchers from the departments of nephrology, mechanical engineering, pathology, biomedical engineering, radiology, cardiology, pharmacy and community nephrologists.

http://healthnews.uc.edu/news/?/5501/

In order to reduce the problems linked with hemodialysis vascular-access dysfunction, Roy-Chaudhury, UC surgeons Rino Munda, MD, and Steve Woodle, MD, and colleagues in engineering, radiology, cardiology and pathology have established the Cincinnati Dialysis Access Research Program (CAP).

http://healthnews.uc.edu/news/?/10585/

Clinical Trial Examines Gene Therapy for Dialysis Patients

CINCINNATI—A new gene therapy may help sustain dialysis access in patients, eliminating the need for multiple interventions and surgeries and improving their quality of life.

Timmy Lee, MD, UC Health nephrologist, and Rino Munda, MD, UC Health transplant surgeon, are leading a local branch of a national clinical trial looking at the gene therapy product Trinam to see if it prevents stenosis, or narrowing of the veins at the connection of the vein and dialysis graft, in hemodialysis patients.

[QUOTE=Dori Schatell;19791]Mark, this is exactly the point of the Buttonhole technique–cannulating in exactly the same spot, at exactly the same angle, over and over again. Done right (this means by the SAME person at the exact SAME angle–preferably the person with the fistula), this technique has been shown in research to cause fewer missed sticks and fewer aneurysms and bumps. The only problem that has been seen is a risk of infection if the scabs are not removed the right way. But infection is always a risk with any access, and good technique can prevent it.

Unfortunately, the Buttonhole technique is often done wrong:

  1. Staff insist on starting Buttonholes, because they don’t trust patients to use sharps, or they worry about liability. But clinics can rarely assign the same person to cannulate for as many treatments in a row are needed, so 2 or 3 or 4 different staff may try, each with a slightly different angle. This can lead to “coring” – making the hole larger and larger so blood leaks out around it during a treatment, and people say, “that Buttonhole thing doesn’t work, we tried it.” WRONG.
  2. Even if, by some miracle, you can get one staff person to start Buttonholes, it’s unlikely that he or she would cannulate at the same angle that YOU would. So, you’d end up with a Buttonhole that is awkward or difficult for you to use, or where the blunt needle just won’t go in the track. Then people say, “that Buttonhole thing doesn’t work. We tried it.” WRONG again.

I’m glad your doctors are so experienced, but sometimes doctors don’t keep up with what’s new (though the Buttonhole technique was actually first done about 30 years ago). Or, they don’t like change. If it were me on dialysis, I would absolutely use the Buttonhole technique. The data are persuasive, and so are the testimonies of people who use it the right way.

As far as the WAK, I suspect that SOME new machine (maybe not that one) will be on the market within 3 years or so, and there may be several within the next 5-6 years. Folks are going to have more choices relatively soon, I think![/QUOTE]

The problem with that you are telling me is that we did all of the things that you have stated and my fistula had problems after three years. The same nurse, who is outstanding, did the cannulating, each and every day. I was told by the Nurse that I was an “outstanding sticker”, same place, each and every time. I was told that I was good enough to work sticking people at a dialysis clinic. U.C. is where they figured that transplant patients only have to take steroids for a few days and done. Dr. Munda does access surgery, all day, every day! I am very picky about infections, scabs, and washing my hands. I went for three years without getting sick, tell you anything? The Nephrology Nurses at U.C. told me that, “Dr. Munda is the best, not even close.”

[QUOTE=Dori Schatell;19791]Mark, this is exactly the point of the Buttonhole technique–cannulating in exactly the same spot, at exactly the same angle, over and over again. Done right (this means by the SAME person at the exact SAME angle–preferably the person with the fistula), this technique has been shown in research to cause fewer missed sticks and fewer aneurysms and bumps. The only problem that has been seen is a risk of infection if the scabs are not removed the right way. But infection is always a risk with any access, and good technique can prevent it.

Unfortunately, the Buttonhole technique is often done wrong:

  1. Staff insist on starting Buttonholes, because they don’t trust patients to use sharps, or they worry about liability. But clinics can rarely assign the same person to cannulate for as many treatments in a row are needed, so 2 or 3 or 4 different staff may try, each with a slightly different angle. This can lead to “coring” – making the hole larger and larger so blood leaks out around it during a treatment, and people say, “that Buttonhole thing doesn’t work, we tried it.” WRONG.
  2. Even if, by some miracle, you can get one staff person to start Buttonholes, it’s unlikely that he or she would cannulate at the same angle that YOU would. So, you’d end up with a Buttonhole that is awkward or difficult for you to use, or where the blunt needle just won’t go in the track. Then people say, “that Buttonhole thing doesn’t work. We tried it.” WRONG again.

I’m glad your doctors are so experienced, but sometimes doctors don’t keep up with what’s new (though the Buttonhole technique was actually first done about 30 years ago). Or, they don’t like change. If it were me on dialysis, I would absolutely use the Buttonhole technique. The data are persuasive, and so are the testimonies of people who use it the right way.

As far as the WAK, I suspect that SOME new machine (maybe not that one) will be on the market within 3 years or so, and there may be several within the next 5-6 years. Folks are going to have more choices relatively soon, I think![/QUOTE]

There are many issues other than proper buttonhole technique that can effect ones fistula. I also was following what I was taught. Its the items that they dont disclose to you are what usually get you in trouble.
When I first started hemo 5 years ago, no one every warned me that higher blood flows can ( and did) have an effect on the longevity of my fistula.3 years of running at a 400 blood flow with a very tiny fistula took its toll last april. The turbulance from the high flows damaged my vessel walls and caused scarring which led to several bouts of stenosis and angios and balooning.
If I would have know beforehand that high pressures could do this, I would have run lower flows which I am forced to do now.
Different people react to different circumstnaces. Just because a 400 blood flow damaged my fistula doesnnt mean its going to damage everyone who runs at 400. This is why dialysis should be individualized towards the person and not out of a book or training manual.

This is why we need to educate ourselves as much as possible.

PS…
Dori -
do you have any information on using a Bovine Coratid Artery to revise a segment of stenosed area in a fistula? This is an option for a revision of my fistula. They would like to use approx 1 inch of decellularized bovine carotid artery and use it to bypass the stenosed area. I do know Massachusetts General did a study that is not released yet on this very topic.

Comparison of Bovine Carotid Artery and Expanded Polytetrafluoroethylene (ePTFE) for Permanent Hemodialysis Access
Sponsor: Massachusetts General Hospital
Collaborator: Artegraft, Inc.

Information provided by: Massachusetts General Hospital
ClinicalTrials.gov Identifier: NCT01021839

I would still be able to use my current buttonholes.
Im just wondering if you had any studies or heard of any centers that use bovine for fistula revision. I know it was used many many years ago and is making its way back as a tool to use.
Suposidly the bovin artery is better than a graft, but not as good as your own vein. Since I have no other options, this is what it has come down to. There is not a single veing in my body to use for a patch or revision let alone a new fistula…

///MM
Brian

You are correct, MM, 400 and above blood flow rates can ruin the fistula. However, it depends on the individual and we are individuals, not a training manual. This is why I have pushed DaVita about the Expanded Treatments, for the low blood flow is a major reason, to protect our fistulas and hearts. We want real fistuals, nothing else.

Mark

[QUOTE=MiracleMan;19794]There are many issue

s other than proper buttonhole technique that can effect ones fistula. I also was following what I was taught. Its the items that they dont disclose to you are what usually get you in trouble.
When I first started hemo 5 years ago, no one every warned me that higher blood flows can ( and did) have an effect on the longevity of my fistula.3 years of running at a 400 blood flow with a very tiny fistula took its toll last april. The turbulance from the high flows damaged my vessel walls and caused scarring which led to several bouts of stenosis and angios and balooning.
If I would have know beforehand that high pressures could do this, I would have run lower flows which I am forced to do now.
Different people react to different circumstnaces. Just because a 400 blood flow damaged my fistula doesnnt mean its going to damage everyone who runs at 400. This is why dialysis should be individualized towards the person and not out of a book or training manual.

This is why we need to educate ourselves as much as possible.

PS…
Dori -
do you have any information on using a Bovine Coratid Artery to revise a segment of stenosed area in a fistula? This is an option for a revision of my fistula. They would like to use approx 1 inch of decellularized bovine carotid artery and use it to bypass the stenosed area. I do know Massachusetts General did a study that is not released yet on this very topic.

Comparison of Bovine Carotid Artery and Expanded Polytetrafluoroethylene (ePTFE) for Permanent Hemodialysis Access
Sponsor: Massachusetts General Hospital
Collaborator: Artegraft, Inc.

Information provided by: Massachusetts General Hospital
ClinicalTrials.gov Identifier: NCT01021839

I would still be able to use my current buttonholes.
Im just wondering if you had any studies or heard of any centers that use bovine for fistula revision. I know it was used many many years ago and is making its way back as a tool to use.
Suposidly the bovin artery is better than a graft, but not as good as your own vein. Since I have no other options, this is what it has come down to. There is not a single veing in my body to use for a patch or revision let alone a new fistula…

///MM
Brian[/QUOTE]

[QUOTE=MiracleMan;19794]PS…
Dori -
do you have any information on using a Bovine Coratid Artery to revise a segment of stenosed area in a fistula? This is an option for a revision of my fistula. They would like to use approx 1 inch of decellularized bovine carotid artery and use it to bypass the stenosed area. I do know Massachusetts General did a study that is not released yet on this very topic.

Comparison of Bovine Carotid Artery and Expanded Polytetrafluoroethylene (ePTFE) for Permanent Hemodialysis Access
Sponsor: Massachusetts General Hospital
Collaborator: Artegraft, Inc.

Information provided by: Massachusetts General Hospital
ClinicalTrials.gov Identifier: NCT01021839

I would still be able to use my current buttonholes.
Im just wondering if you had any studies or heard of any centers that use bovine for fistula revision. I know it was used many many years ago and is making its way back as a tool to use.
Suposidly the bovin artery is better than a graft, but not as good as your own vein. Since I have no other options, this is what it has come down to. There is not a single veing in my body to use for a patch or revision let alone a new fistula…

///MM
Brian[/QUOTE]

I’m afraid your post is the first thing I’ve heard about a return for bovine grafts, but I’ll check around.

Hi Brian,
I haven’t heard back yet from the couple of people I emailed, but I’m putting together the email update for this month, and ran across an abstract that I thought might be of interest to you, since you said you have no access sites left:

Nephrol Dial Transplant. 2010 May;25(5):1588-95. Epub 2009 Dec 18.

Translumbar central venous catheters for long-term haemodialysis.
Power A, Singh S, Ashby D, Hamady M, Moser S, Gedroyc W, Taube D, Duncan N, Cairns T.

Imperial College Kidney and Transplant Institute, West London Renal and Transplant Centre, Imperial College Healthcare Trust, Hammersmith Hospital, DuCane Road, London W12 0HS, UK. albert.power@imperial.nhs.uk

Abstract
BACKGROUND: Vascular access for haemodialysis is achieved by tunnelled central venous catheter (CVC) in at least 23% of prevalent patients in the UK, Canada and the USA. Use of CVCs is associated with an increased incidence of venous stenosis that can progressively limit future vascular access routes. Lack of conventional venous access routes mandates the use of alternative strategies such as the translumbar approach. METHODS: We retrospectively analysed patients at our centre requiring translumbar inferior vena caval CVCs (TesioCath) for haemodialysis in the period 1999-2008. Written and electronic records capturing dialysis adequacy and complications, hospital admissions and laboratory data were examined. RESULTS: Thirty-nine pairs of translumbar CVCs were inserted in 26 patients with 15 864 catheter days follow-up, mean patient age 61.9 +/- 12.1 years, 31% diabetic, 15% with ischaemic heart disease. All insertions were successful. Insertion of one CVC was associated with a self-limiting retroperitoneal haematoma. No patients died of a catheter-related cause or through lack of vascular access. Cumulative assisted primary catheter site patency was 81% at 6 months and 73% at 1 year (median 18.5 months). Good dialysis adequacy was achieved throughout (mean single-pool Kt/V 1.5 +/- 0.4). The incidence of access-related infection was 2.84/1000 catheter days (exit site infection rate 2.02/1000 catheter days; catheter-related bacteraemia rate 0.82/1000 catheter days). Catheter dysfunction (need for thrombolytic infusion or catheter change) led to 0.88 admissions per 1000 catheter days. CONCLUSION: Translumbar inferior vena caval CVCs can offer relatively safe and effective long-term haemodialysis access in patients with no other options.