Dr. Noam Spinowitz is a leading expert in dialysis access management. In this interview, Dr. Spinowitz explains the different types of dialysis access and catheter placements.
How to Decide Which Type of Dialysis is Right for You?
Of the many functions that the kidneys have in the body, some of the major functions are to get rid of the toxins that are built up in the bloodstream and to maintain a balance of fluid and electrolytes. If somebody’s kidneys decline in function, the patient will require dialysis to achieve these effects.
The patient will have to discuss with their nephrologist, family, and support system what mode of dialysis they will require. There are two different modes. One is peritoneal dialysis and the other one is hemodialysis. Sometimes patients come to me to review the pros and the cons of each mode of dialysis. Again, these decisions will need to be made with the primary nephrologist, the patient’s family, and support system. The decision is very complex and will be very subjective. It will depend on the patient’s lifestyle and what they want to achieve.
A pro for peritoneal dialysis is to gain independence. The patient can go about their daily life with peritoneal dialysis because it can be performed at home, or at night. This leaves the day for the patient to do whatever they normally do, whether it’s work or travel, or just go on with their daily business. A con for peritoneal dialysis, as patients have told me, is that they don’t like their home to look like a hospital. They need to store some of the bags for the peritoneal dialysis and then have a place to dispose of everything.
A pro for hemodialysis is that the patient can go to a dialysis unit, and the dialysis unit, with the nurses and technicians, can perform hemodialysis for them. A con of hemodialysis is that a patient will require cannulation, or sticking a needle into the fistula or the graft, which is underneath the skin, to achieve hemodialysis.
Once the decision is made as to which mode of dialysis the patient will undergo, the patient can be sent to one of our outpatient vascular centers, where the appropriate procedure can be performed so that the patient can receive either peritoneal dialysis or hemodialysis. If they require peritoneal dialysis, the patient will need a peritoneal dialysis catheter to be inserted into the abdomen. If the patient will require hemodialysis, the patient can initially require a hemodialysis catheter to be placed in the chest or to have a fistula or graft created underneath the skin for dialysis.
How Do You Prepare for Dialysis?
There is not much preparation for dialysis. However, the patient cannot eat for approximately six hours before the procedure. The reason why we do not want the patient to eat prior to coming for the procedure is that we want to provide anesthesia for the patient. The type of anesthesia that we perform here is conscious sedation; we give Fentanyl and Versed. Fentanyl is a pain reliever, and Versed is an anxiolytic.
We want the patient to be relaxed. We are not going to knock the patient out completely because this is an outpatient procedure. The procedures that we perform generally do not require heavy sedation. We would rather perform the procedures in a safe manner, where the patient can get up post-operatively after 20-30 minutes of observation and go on about their day.
If the patient needs a hemodialysis procedure, whether it’s a catheter insertion for the hemodialysis catheter, or fistula or graft creation or maintenance, the patient will not require any IV (Intravenous therapy). If the patient is coming for a peritoneal dialysis catheter because there is no access to the patient’s circulation, the patient will require an IV to receive these medications.
How Does a Dialysis Catheter Placement Work?
There are two types of dialysis catheter placements. There’s a hemodialysis catheter and a peritoneal dialysis catheter.
Hemodialysis Catheter Placement
The first, the hemodialysis catheter, is a catheter that has two ports. There’s an arterial port where the blood comes out of the catheter into the dialysis machine to clean the blood. Once the blood is clean, it’s then returned to the body through the venous port. This catheter is placed into the internal jugular vein, usually on the right side but can be placed on the left as well. The right internal jugular vein drains the blood from the head down back toward the heart in a straight fashion. The skin is anesthetized just at the base of the internal jugular vein before it connects to the brachiocephalic vein deeper in the chest. The skin is anesthetized with a small bit of lidocaine, which can cause a little bit of a pinch and burn for a few seconds. A small needle is then introduced into the internal jugular vein using ultrasound guidance. Once we are in the internal jugular vein, a wire is placed deeper into the central circulation to stabilize the system. Images are taken.
The subcutaneous tissue is then anesthetized from underneath the collar bone, all the way until the insertion point at the internal jugular vein. Once this area is anesthetized, a small incision is made just underneath the collar bone, and the catheter can then be introduced into the skin, underneath the skin, brought out from this area, where we went into the internal jugular vein, and then introduced into the internal jugular vein. When you leave here, the catheter will come out from the chest wall. Everything else is underneath the skin. You can feel the catheter underneath the skin over the collar bone just before it enters into the internal jugular vein. After that, you don’t feel it. The tip of the catheter will then be resting at the entrance into the heart.
Peritoneal Dialysis Catheter Placement
The second type of catheter is the peritoneal dialysis catheter. This type of catheter is placed into the abdomen to perform peritoneal dialysis. I’m going to draw a picture of the abdomen and how we place the peritoneal dialysis catheter to make it clear. If we were to take a picture of the patient’s abdomen and sort of cut it in half, from the top down, we would see the skin, we would see some fat or tissue underneath, some muscle under there, and underneath there, the peritoneum, which is why it’s called peritoneal dialysis. This peritoneum is a very thin lining and it goes around the whole abdomen.
Inside the abdomen are the intestines. The intestines are filled and lined with a lot of blood vessels. This is the blood that is being carried to the intestine that has not yet been cleaned because the kidneys are not working. The peritoneum, this thin layer that looks like a stocking, goes around the intestines as well. Now we have space, this peritoneal space, that is outside of the intestines but underneath the layers, we described before. This thin layer of the peritoneum can act as a filter because it’s a very thin layer on the other side of the blood vessels. In order to perform peritoneal dialysis, we will make a small incision next to the belly button, around 1-2 centimeters.
With ultrasound guidance, after numbing up this whole area, we insert a needle through this area. Once we are in the peritoneal space, between the peritoneum and the intestinal wall, we introduce a wire to go down deep into the pelvis. With this introduction of the wire, some patients can feel pressure, some patients don’t feel it at all. Once the wire is in the appropriate position, we place the catheter. Just like we did before with the hemodialysis catheter, we bury the catheter underneath the skin to prevent it from infection.
This catheter can then allow the dialysate to enter the peritoneal space. There are a lot of holes on the peritoneal dialysis catheter to allow the dialysate to go throughout the abdomen, allowing the toxins to flow from the blood across the filter, the peritoneum, into this space. This allows all the toxins to be removed just like gravity. After the exchange takes place, all the toxins then come out, and here is the waste. You will have a small incision here, which will be sutured. Underneath, those sutures will resorb by themselves. This is the exit site, where the catheter comes out.
How Long Does a Dialysis Catheter Placement Take?
For a catheter insertion or exchange procedure, the patient’s time in the procedure is approximately 10-20 minutes. There is a pre-op time, a prep time, and a post-op time, but the actual procedure time is approximately 10-20 minutes. If it’s a more in-depth maturation or thrombectomy procedure of a fistula or a graft, the procedure time can be approximately 30-60 minutes. If the patient presents for maintenance of the fistula or graft and will require angioplasty or stent placement, the procedure time can take typically anywhere between 15-20 minutes.
What Should You Expect After a Dialysis Catheter Insertion?
For a catheter insertion procedure, whether it be peritoneal or hemodialysis catheter insertion or catheter exchange, the patient can experience some soreness after the fact. The patient usually can complain of some soreness at night or the morning after. Any pain that may occur can be relieved with Tylenol or ice.
Patients normally do not require any heavy pain medication after the procedures. The patients that present with thrombosis or swelling or pain due to pressure within the access, most of them will actually feel better after the procedure as we relieve the pressure, improving the flow through the fistula or graft, and allowing them to return to normal.
Request a Consultation with Dr. Spinowitz
Dr. Noam Spinowitz knows what it takes to help medical professionals treat dialysis patients and lead longer, more comfortable lives. If you need dialysis access management, request a consultation with Dr. Spinowitz at Harlem Endovascular today.