Friday, April 9, 2010

Fistula First...or Second or Third!

My husband Steve has been in the ICU now since 3/5/2010. He's had an angioplasty, then a major open heart surgery to replace his severely stenotic aortic valve and bypass four coronary vessels. He was so unstable that his chest was left open -- to be closed in a second surgery five days later. I had never even heard of this before! We are so grateful he survived.

Steve's dialysis fistula in his forearm "went down" on the day of his surgery. His cardiac ejection fraction was only fifteen percent (normal is at least over 50 percent), so peripheral blood flow was sluggish. The fistula clotted -- and Steve's condition was so precarious that he required twenty-four-hour-a-day dialysis via an Internal Jugular central line.

Even though Steve has had two prior central lines for Home Hemodialysis, we know that a central line is an infection waiting to happen! They say it's not a matter of if there will be an infection, but rather, when!

(We have been very fortunate with Steve's central lines in the past -- even using them for many months without infections.)

But this time feels more critical. In Steve's already weakened state, we cannot risk a line infection. So, the current plan is to place a new dialysis fistula this coming week. We know it will take weeks to mature to the point where it's usable for dialysis.

All this brings me back to the point of the slogun "Fistula First!" In the best of circumstances, a person with End Stage Renal Failure starts Hemodialysis via a mature fistula, surgically created weeks to months in advance. This is why patients are referred to a vascular surgeon as their renal function nears the point of dialysis (as reflected by the eGFR- or estimated glomerular filtration rate). In general, dialysis would begin with an eGFR of 10, or 15 in a diabetic.

Back in September of 2007, Steve's initial presentation with acute-on-chronic renal failure was so rapid, he didn't have the luxury of getting a fistula placed ahead of time. Even then, he couldn't seem to catch a break. But, even then, he landed on his feet. We're counting on continued strength from this extraordinarily resilient man.

Take care. Linda Gromko, MD


  1. Will Steve be able to have another fistula in an arm? I am most concerned that if my current fistula fails I have no arm locations left for an alternative fistula due to peripheral vascular disease. Are there any other fistula locations other than groin area ones thst you know of?


  2. Hi Miriam,
    While Steve has an alternative site mapped on his other forearm, there is now talk about doing an angioplasty on the clotted fistula -- at least, that's what I've heard. I don't know of other sites, except upper arms, thighs -- and, of course peritoneal dialysis. There's always central line access with its drawbacks. I hope you are doing well. Linda