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Arterial disease

There are several reasons to experience pain with hemodialysis. The most common source of the pain is experienced during cannulation (inserting large-bore needles into the skin and the vein) prior to hemodialysis. This is expected since the needles for hemodialysis have a larger diameter. However, over the course of 2 to 3 months, the skin will build scar tissues over the cannulation sites and the patient feels pressure instead of pain upon cannulation.

Other sources of pain during hemodialysis can be from poor perfusion to the distal limb where the dialysis access has been placed. The patients who experience pain, numbness or feeling of pins and needles with unbearable throbbing in their hands and fingers either immediately after the creation of arteriovenous shunts graft or during hemodialysis may be experiencing something called “The Steal Syndrome”. In this condition, the blood is directed more into the dialysis shunt than the distal extremity. The involved hand then has very poor baseline perfusion which leads to demand ischemia. If this condition persists or worsened, the patient may develop permanent nerve damage and tissue loss with risk for major limb amputation. Patients should immediately seek help from their vascular surgeon if they are experiencing pain in their hand with AVF/AVG on the same extremity. This condition can be surgically corrected and saves the patient from any future limb loss.

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It depends on the site of the creation, the diameter of the vein, and the blood flow in the vein. Usually, it takes within 4 to 6 weeks for a vein to get large enough and strong enough to be able to withstand cannulation and the high pressure from hemodialysis. If the vein fails to reach the proper size which is usually 6 mm or greater then more procedures needed to help the fistula to achieve its proper size otherwise “to mature”.

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Depending on the extent of the surgical procedure, the patient expects mild-to-moderate pain from the site of the procedure with slight edema and ecchymosis. If the pain continues and the patient feels numbness and problem moving their hand/fingers they should contact their surgeon immediately. The surgical scar usually takes about 4 to 6 weeks completely healed.

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  1. Nothing to eat or drink past midnight before the surgery.

  2. There surgeon should tell you which arm the surgery is going to be performed so wash your arm is soap and water and keep your skin clean.

  3. If you are taking a blood thinner/anticoagulation medication such as Warfarin/Coumadin, Xarelto, Eliquis or Pradaxa is it best to hold the medication at least five days prior to the surgery with approval of your primary care physician or the surgeon. If you have any questions, please call your surgeon.

  4. It is okay to continue with antiplatelet medication depending on the extent of the surgical procedure.

  5. If you are diabetic and taking oral anti-glycemic medications to control their blood sugar it is best to hold the medication when you are fasting to avoid hypoglycemia prior to the operation.

  6. Your diabetic and taking insulin injections to control your blood sugar, it is best to hold insulin injections when you are fasting to avoid hypoglycemia prior to the operation.
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There are many ways to create arteriovenous shunts for hemodialysis. The simplest way is to connect the vein to the artery at the wrist via a small incision. However, many patients may not have open veins over there forearm due to multiple hospitalization and blood drawn or angiocath placement. These patients’ veins from the upper arm are utilized to create arteriovenous shunts and sometimes it may require more involved operation.

There are many patients who simply have run out open veins most likely due to their anatomy or multiple Angiocath placements. These patients a conduit (ePTFE, collagen-based, or Autogenous) is used to connect the artery to the vein and serve as the axis side for the dialysis cannula for the hemodialysis. There are few patients who have had multiple operations for creations of arteriovenous fistula/graph with failure. These patients simply have no larger veins to connect the conduit to. In these patients a new method called hero catheter is used to direct the flow directly into the heart from the upper and/or lower extremities arteries.

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There are two different types of dialysis, hemodialysis, and peritoneal dialysis. In hemodialysis, blood is pumped from the patient into the dialysis machine in which the blood is ultra-filtered and the extra fluid with unwanted substance will be removed and the cleaned blood is returned back into the patient’s body. With peritoneal dialysis, the peritoneal membrane, a thin-walled membrane within the abdominal cavity can exchange extra fluid and unwanted substances across itself into the dialysate fluid that has been pumped into the abdominal cavity via a catheter that has been placed or permanently. After this exchange has occurred the dialysate is then removed from the abdominal cavity via the catheter.

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There are five stages of renal failure the last stage is referred to and the stage renal disease (ESRD) or stage V. Patients with ESRD, have less than 15% of their normal renal function. Patients with ESRD require either hemodialysis or kidney transplant to stay alive. Therefore, it is very important to consult with a vascular surgeon in patients on stage four of the renal failure.

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Limb amputation is the curative treatment for nonviable for non-salvageable limb. Patients who undergo major or minor limb amputation may have to change major modifications in the lifestyle for their disabilities. Patients who undergo major limb amputation such as above the knee amputation have to spend up to 60% more energy to ambulate care to healthy individuals. Many patients will undergo major limb amputation mean have to utilize wheelchair or motorized scooters to get their chores done.

However, the goal of major limb amputation is to achieve complete one healing and improving quality of life by giving the patient second chance to live without infection, pain and open wound. It is very critical to identify the best level of amputation for every patient. Patients with nonhealing wounds and welding the foot and lower legs should seek a consultation with vascular surgeon regarding the process of living amputation.

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One-third of the patients with symptomatic PAD will get worse during the course of their disease and may develop rest pain with or without skin ulcers. This condition is called critical limb ischemia (CLI).

Some experts consider believing CLI is a systemic condition rather than a local malperfusion to a limb. Patients with CLI have a higher chance of major limb amputation, death or any major disability and compares the patient was just PAD. Early intervention with a multidisciplinary approach is the best way to treat CLI.

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There are several ways to treat PAD. Upon diagnosis of PAD, the patient can be given instructions for routine exercises, cholesterol-lowering medication(s) and diet modification. One-third of the patients will improve their symptoms just by schedule exercise, medications and diet and lifestyle modifications such as smoking cessation.

One-third of the patients will not achieve any improvement continue to have symptoms despite following instructions and conservative treatments. One-third of the patient and even get worse despite the treatment as well. It is very important to consult with a vascular surgeon/specialist right away upon diagnosis of PAD.

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The simplest test diagnose PAD is ankle brachial index (ABI). ABI is a simple noninvasive test that can be performed at the clinician’s office. It simply measures the blood pressure at the ankle and the arms, and it divides the ankle or the highest on pressure. The ABI of 0.9 and less is diagnostic for PAD.

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Commonly atherosclerotic plaque involved the aorta and its branches most commonly lower extremities. The symptoms are tightness and cramps most commonly involving lower extremities particularly calf muscles which is relieved by rest. Individuals with PAD usually complain of having difficulty performing their daily activities due to inability to ambulate.

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Peripheral arterial disease (PAD), commonly refers to formation of atherosclerotic plaque within the wall of the blood vessels outside of the heart and its surrounding arteries. The plaque formation can happen over a period of time most likely due to inflammations within the wall of the blood vessels. There are many risk factors attributing to formation of atherosclerotic plaques within the arteries. The three most common risk factors are, older age, smoking, and genetics.

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