Home Hemodialysis and question on location of AV Fistula

[komomai]

Aloha All,

I'm trying to do home hemodialysis here in Okinawa, Japan.  It's too bad that Japan doesn't have the NxStage system so there are going to let me use a Nikkiso full size dialysis machine.

But my question is I had a tunnel catheter which has been removed due to an infection.  Now have a temp. catheter awaiting a placement of an AV Fistula, issue is my access point it seems like they are looking at my upper arm location.  Do any of you who do home hemodialysis with an upper arm fistula insert your own needles? 

I have 2 doctors who I deal with, one seems to think that it's not possible while the other one thinks it's possible.  The one that says it's not possible also said it depends on how deep my veins and arteries are, but from what I've seen of the procedure they will try to bring the vein and artery close to the surface of the skin and tunnel either the vein or artery (don't remember which one).

Any help or advice would be greatly appreciated as I need to get off these catheters just way too much infections.

[cattlekid]

Hello!

I had an upper arm fistula in my left arm.  I am right handed.  My fistula is on my left bicep and I found it very easy to insert and even remove the needles with my right hand.  I guess if they had to put it in your arm with your dominant hand, it would be a lot tougher unless you are truly ambidextrous.

[cassandra]

Hi, I've my fistula in my dominant upper arm. I'm not truly ambidextrous, but used to play games on my phone with my left (wrong) hand to practice the fine motoric skills. Works a treat. Buttonholes, or sharps.
So start practicing, get off the caths, and proof them wrong.

Good luck

[komomai]

Aloha cassandra and cattlekid,

Mahalo for your responses, I go to see a supposedly good vascular surgeon on Wednesday at a different hospital, the cool thing is that my doctors at the hospital I'm in recommended him as doing diffucult AV Fistulas.  The cool thing of doing dialysis here in the Japanese hospitals is that the doctors come by to each patient and look at their chart and ask them how their doing.  When Dr. Higa came by my chair, I asked him for more details, he brought out the echo machine and showed me where my veins and arteries where and showed where the AV Fistula would be and explained that I would insert the needles with a 4-5 cm gap between and the needles would go in opposite to each other.  I then asked the nurses to bring out the sharps and blunt needles and show me the different types, they suggested that when I'm ready I should try each one to find the one that I would prefer.  Again this is with my very limited Japanese vocabulary but it seems we get the point across.  In the meantime I have asked to put back in a tunnel catheter so I can get out of the hospital and get back to work, again Dr. Higa mentioned that the vascular surgeon might put in a tunnel for me and do the AV Fistula so that I can use the tunnel catheter while I give the Fistula enough time to heal real good before using.

Cattlekid , I am right handed and the plan is to put it in my upper left arm.

Cassandra, yes totally agree I want to be rid of the catheters hopefully for good and these infections really take a toll on me.

Really looking forward to taking control of my own dialysis in the comfort of my own home and my own times. 

Mahalo for responding.

[Hemodoc]

Aloha All,

I'm trying to do home hemodialysis here in Okinawa, Japan.  It's too bad that Japan doesn't have the NxStage system so there are going to let me use a Nikkiso full size dialysis machine.

But my question is I had a tunnel catheter which has been removed due to an infection.  Now have a temp. catheter awaiting a placement of an AV Fistula, issue is my access point it seems like they are looking at my upper arm location.  Do any of you who do home hemodialysis with an upper arm fistula insert your own needles? 

I have 2 doctors who I deal with, one seems to think that it's not possible while the other one thinks it's possible.  The one that says it's not possible also said it depends on how deep my veins and arteries are, but from what I've seen of the procedure they will try to bring the vein and artery close to the surface of the skin and tunnel either the vein or artery (don't remember which one).

Any help or advice would be greatly appreciated as I need to get off these catheters just way too much infections.

You should always have a venous ultrasound to define your specific anatomy. Most don't realize that with special microsurgical techniques, placing fistulas in children is quite succesful. The skill of the surgeon is the most important aspect of fistula placement and can make up for less than ideal veins in some cases, but obviously not all.

In general, you should try to avoid an upper arm fistula as the first placement becuase you will not have an opportunity to try on a lower location after that. Lower wrist, mid-forum, upper-forearm then upper arm is the preferred progression. If you have alower wrist location for your first fistula, you still have the option to go higher later.

So, start with a venous US and then see what options you have. Second opinions with a very experience vascular surgeon and if you can find one that performs microsurgical techniques on children, then you may have more options.

[obsidianom]

I agree with Hemodoc, you should try to get it in the lower arm. My wife is very tiny with tiny veins and the first surgeon said no to lower arm. We went to a bigger medical center and had a top notch surgeon do it in the lower arm . He had to do a second surgery later to widen it but it is now very large and works beautifully. Everyone is impressed with it. So try for the lower arm so you can save the upper if needed for later. Also the lower fistula will develop the upper arm vasculature so it will be bigger if needed later. 

[komomai]

Thanks for the advice, the first vascular surgeon that I saw did the echo and said that my veins were good but that my arteries had calcification in them, what he and his boss decided on was to put it mid arm as my wrist wasn't good enough.  But to get around the arteries they wanted to do a graft by cutting my leg, good thing my kidney doctor was looking out for me as he had a long talk with my wife and I, he explained that due to calcification on both legs any kind of cutting would take a long time to heal and this would increase a risk of infection.  Their future plans for my legs is to refer to a cardioligist to do a ballon through both legs to help with the circulation.  The good news is that they refer me to a very good vascular surgeon at another hospital, my appointment is for tomorrow.

So obsidianom you're correct weigh out your options and if not satisified with the first answer, look for a different option.

Hemodoc I already had a ultrasound done, that's how come they saw the calcification in the arteries.  Will see what the new doctor say's as I'll request him to look at my arms again just to make sure.

[amanda100wilson]

I agree with Hemodoc.  That being said, I have upper arm fistula and cannulate myself.  It took three ops to get it useable.  One to lift it towards the surface, and then because surgeon didn't listen to what I was telling him, further op. To locate it from inside of my arm to over my bicep.  After I had had it done, my old neph said that some people have graft first in lower arm, if fistula can't be done there.  Apparently this helps develop vein higher up, to enable fistula formation when graft no longer works.

[cattlekid]

I was beyond pissed with my fistula surgery. I went in thinking they were going to place it in my wrist. When I got out of surgery, I had four scars on my arm and a fistula on my bicep. Thankfully, it worked like a charm or home hemo would have been nothing but a dream.

[komomai]

Update after the visit with a specialist at a second hospital.  He confirmed using the ultrasound that my veins were small and using the wrist and forearm wasn't good, he also explained that the upper arm would take a while to heal in the mean time he would do a tunnel catheter in my leg as my neck one hasn't enough time to heal.  All this would take time and since I'm still working, I was running out of sick and annual leave and would have to go on LWOP soon.  During lunch my wife and I disscussed my options, and when we went back to him I asked what would be the quickest way for me to get back to work and out of the hospital(they won't let me leave because of the temp. catheter in my upper leg.  He said to put a graft using the tube tied to the veins and arteries it would look like a "U" on my forearm area.  Hospital stay would be mininmal and I could start my training to do my own needles and get a machine to do home dialysis.  He also told me that my original hospital could do the procedure, so I need to ask my Doctors for this procedure.

When he asked me why I need to do it quickly and when I told him "work" he was amazed as he told my wife in Japanese that most all of his kidney patients who are on dialysis don't work anymore.  I told him because I do in center dialysis 6 times a week for 3 hours per session, he made a roller coaster motion with his hand and said that's 3 times per week vs. more steady line when you do it more often.

So today I am going to ask my doctors for a graft hose on my left forearm.  I need to get out I've been in the hospital for 24 days now and can't stand the bland food.

[Hemodoc]

One option to avoid a catheter placement and the risks of complications with catheters is to consider Peritoneal Dialysis as a bridge for a few months while the fistula matures. Not sure if that is an option for you medically, or if you are averse to such a consideration, but it is something that I would consider before a catheter.   Just one more thing to possibly consider, but it if is not an option, then it looks like you have at least had a thorough evaluation and answers to your questions.

[komomai]

Aloha Hemodoc, I've tried PD did it for 2 and half years, gained weight on it and caught 2 infections the 2nd one kept me in the hospital for 40 days as it was a rare infection and they were down to trying their last type of antibiotics for it.  So it seems like the catheter is my only option while I build back my sick/annual leave time.  So on Monday afternoon they will place a tunnel catheter in my left leg and I should be dischared from the hospital.  Then I will have time to do the fistula and let it heal.

Mahalo for all the suggestions, I find it helps me a lot to have options when dealing with this condition.  As I told the Japanese vascular surgeon I have had to learn way to much about dialysis but it's the only way I can try to live a normal life.

[Hemodoc]

Aloha Hemodoc, I've tried PD did it for 2 and half years, gained weight on it and caught 2 infections the 2nd one kept me in the hospital for 40 days as it was a rare infection and they were down to trying their last type of antibiotics for it.  So it seems like the catheter is my only option while I build back my sick/annual leave time.  So on Monday afternoon they will place a tunnel catheter in my left leg and I should be dischared from the hospital.  Then I will have time to do the fistula and let it heal.

Mahalo for all the suggestions, I find it helps me a lot to have options when dealing with this condition.  As I told the Japanese vascular surgeon I have had to learn way to much about dialysis but it's the only way I can try to live a normal life.

Best of luck with your procedures, doesn't sound like much fun, but staying the course and keeping on is the goal. Sometimes life doesn't throw us all the best options, but having options is always better than having none. Once again, I hope all goes well with the catheter and your fistula.

Take care,

Peter

[JW77]

YES, I'm right handed, my fistula is in my right upper arm near the elbow.

https://www.facebook.com/photo.php?fbid=10152647994555151&l=8a5320b5ce

I started self needling when I was about 10 years old, using my left hand:)