Minimally-Invasive Procedure Helps Kidney Dialysis Patients
To patients undergoing hemodialysis for end-stage renal disease, unimpeded blood circulation is everything.
Watch the Surgery
View the surgical procedure: angioplasty with vascular stenting and hear remarks from Dr. Kontos.
During hemodialysis, a machine takes the place of the kidneys, pumping blood from the patient's body through flexible tubing, cleaning it and then returning it to the patient's body through a separate tube. To connect to the machine, called a hemodialyzer, an access into the patient's blood vessels must be created.
When an artery or vein carrying blood to or from a patient's dialysis access site, usually an arm or leg, narrows or develops a blockage, the limited blood flow makes hemodialysis more difficult and less effective.
To restore blood flow, George Kontos, Jr., M.D., uses a minimally invasive treatment for the long-term management of vascular access in kidney dialysis patients. The procedure, an angioplasty with vascular stenting, is done at Genesis Medical Center, Silvis.
Improving Quality of Life
According to the Congressional Kidney Caucus, more than 475,000 Americans have irreversible kidney failure, or end-stage renal disease (ESRD), and need dialysis or a kidney transplant to survive.
Most patients on dialysis require a maintenance procedure - either a balloon angioplasty or an angioplasty and stent - once or twice a year to maintain adequate blood flow to their access site.
Dr. Kontos, a thoracic, vascular and general surgeon with Genesis Health Group, Surgical Associates, says the ability to perform percutaneous, catheter-based interventional procedures gives dialysis patients a new outlook on life.
"Before we had catheter-based procedures, these patients would come into the operating room for open procedures, which required hospital stays and a lengthy healing process," says Dr. Kontos. "That was on top of dialysis three or four times a week. It was easy for them to just give up."
In addition, catheter-based procedures allow the physician to reach a blockage or stenosis (narrowing) that could not be reached through a routine open operation. In the past, the blockages would have gone untreated and as a result, a new dialysis access with better blood flow would have to be created for the patient.
"These minimally-invasive procedures require only a few hours in the hospital, have better outcomes and are much more adaptable to the patient's lifestyle," Dr. Kontos says. "Now, they're more compliant and happier."
Patients are referred to Dr. Kontos by their nephrologist when measurements during dialysis indicate low blood flow, excessive pre-pump arterial pressure or high venous pressure.
Cath Lab Procedure
In the procedure, Dr. Kontos uses imaging techniques to perform the procedure. He first conducts an angiogram, an x-ray test that uses a special dye and a camera called a flouroscope, to take pictures of the blood flow around the patient's dialysis access site in the right arm.
During the angiogram, a thin tube called a catheter is placed into the dialysis access site and guided to the area to be studied. The dye, or contrast material, is injected into the vessel to make the area show clearly on the X-ray pictures.
With a narrowing identified by the angiogram, Dr. Kontos then performs an angioplasty, advancing a small, balloon-tipped catheter to the stenosis. The balloon is then inflated to open the outflow vein, deflated and removed.
In the third part of the procedure, Dr. Kontos uses the catheter to place a tiny wire mesh tube called a stent, permanently in the newly opened vein to help it remain open.
The procedure requires constant decision-making.
"During the course of a procedure, we must determine if there's a narrowing or blockage, how severe it is, the best way to open it and how to keep it open, and what catheters to use in what sequence," says Dr. Kontos. "These procedures do have some complications, and we need to avoid them. But because of our experience, we're able to make ongoing decisions during the course of the procedure that result in an effective outcome for the patient."
Managing Vascular Access
While the procedure done by Dr. Kontos is an interventional, maintenance procedure, his comprehensive management of vascular access in patients with kidney disease also includes construction of the actual dialysis access points.
One, called an arteriovenous fistula, is created during minor surgery that directly connects an artery to a vein under the patient's skin. The resulting bigger blood vessel makes repeated needle insertion easier and allows for proper blood flow during dialysis.
Other access options include joining an artery and vein under the skin with a synthetic tube, creating an arteriovenous graft, or placing a temporary catheter on the side of a patient's neck, under the collarbone or in the leg near the groin.
"I believe patients with chronic kidney disease have the greatest need for improvement in their quality of life. When we can take minimally invasive steps that maintain the patency of blood vessels, we add several years of longevity to a patient's dialysis access, instead of having to make a new one," says Dr. Kontos. "Patient and family have a much easier time with the dialysis process. It's very personally rewarding and it really rallies the patient so that they want to go on with life."