A Day In The Life of Sunshine

What happened in the missing hours, Mrs. Carlsen?

2012-02-17T07:06:00.000-06:00

"When was the last time, you ever saw the sunrise?" Emotions conflict:

This morning I can hear my robin singing it's wake up call, it's February 17th, my robin's back in Illinois way too early for him/her to be happy long, another cold snap will come, harsh on someone looking for earthworms, I go to the front window and hear the funny clicking noise you'll hear from a tree or bush in warmer seasons, I love it and laugh as it's a cardinal hopping from branch to branch, it's just starting to get some light to the sky, I love nature and what it brings to my life even in february, you have to stay tuned to soak it in.

The headline saddens me, on February 13th a woman in the next town had her bags packed, Limo ordered to pick her up the next morning for a trip to Florida to meet up with her husband, by my birthday the 15th they had figured out through the limo driver, friends and family, that she never kept that appointment for the airport and trip, she and her car were missing.
By the 15th afternoon they found her car in an un-incorporated road in Wauconda, I worried for her and her safety, wondering what had gone wrong, did she meet someone, did she get snagged along the way, not the best area to be alone, and so the mind wanders.
She was found yesterday on a patch of land not terribly far from the car within a few blocks, she had an empty water bottle near her, and two bottles of emptied pills. The Lake County Coroner office is now in possession of Marie.
Heart for the family, all the questions, all the surprise, she had packed her grandsons Valentine's Day card, all the intentions of making the trip were there. What happened to you after the luggage was packed? What shaped or unglued in the missing hours? Will anybody really ever know? When I saw your picture earlier in the week you reminded me of someone, my thoughts wander to all the women on friday nites of old, out for dinner with friends, and some lighthearted dancing to the live music of the 60, 70 & 80's all of us enjoying that at the very least we were still alive, we'd make our own fun for a few hours and that served to carry us through the week.

And as your story unfolded, I prayed you'd be found okay, you could be any women. You could one of us.
Your story has touch our hearts, and we are saddened that this became your path, that your family is left with this.
All of those years to get to this.

Loves Definitions

2012-02-14T07:55:00.000-06:00

Familial Love, a long journey with a group of people: Parents, Siblings, their Spouses, their children, their children's children, so many adventures, good times, bad times, love and laughter, many years passed together, and then all hitting the finish line at different ages and stages.
First Loves, romantic, huge and usually thrown away by one of the originators.
Love of your life, you've fallen in love with each other, you're not sure where you're going but you want to go there together, many learning curves here: coming to really know each other, co-existing in the same rooms, feeding each other through foods, spirituality, sharing the mind and matters of the heart as they occur, sharing humor, co-existing with each others families, bringing a child into the world together and trying to rear that child, trying to maintain some common interests in real life so your road won't fork off, once people hit that fork and they've wander far enough, it's hard to know if the path crosses over again up ahead, too many are not that lucky and can't seem to find their way back, every once in awhile someone has the good fortune to land back on the path side by side, and here is where some luck of character comes in, sometimes they fall in love with one another again, they find out that this entire journey was shared by the same two souls that started out years back. Time has taught you whom to value highly, and who to back burner.
It is this wonderful word love that makes the journey of life so warm.

St Valentine's Day in Chicago on Clark Street

2012-02-14T05:23:00.000-06:00

Always an interesting piece of Chicago's History or another February time landmark was this little diddly:

During the Prohibition era, gangsters ruled many of the large cities, becoming rich from owning speakeasies, breweries, brothels, and gambling joints. These gangsters would carve up a city between rival gangs, bribe local officials, and become local celebrities. By the late 1920s, Chicago was split between two rival gangs: one led by Al Capone and the other by George "Bugs" Moran. Capone and Moran vied for power, prestige, and money; plus, both tried for years to kill each other.

In early 1929, Al Capone was living in Miami with his family (to escape Chicago's brutal winter) when his associate Jack "Machine Gun" McGurn visited him. McGurn, who had recently survived an assassination attempt ordered by Moran, wanted to discuss the ongoing problem of Moran's gang. In an attempt to eliminate the Moran gang entirely, Capone agreed to fund an assassination attempt and McGurn was placed in charge of organizing it.

The Plan
McGurn planned carefully. He located the Moran gang's headquarters, which was in a large garage behind the offices of S.M.C. Cartage Company at 2122 North Clark Street. He selected gunmen from outside the Chicago area, to ensure that if there were any survivors, they would not be able to recognize the killers as part of Capone's gang. McGurn hired lookouts and set them up in an apartment near the garage. Also essential to the plan, McGurn acquired a stolen police car and two police uniforms.

Setting Up Moran
With the plan organized and the killers hired, it was time to set the trap. McGurn instructed a local booze hijacker to contact Moran on February 13. The hijacker was to tell Moran that he had obtained a shipment of Old Log Cabin whiskey (i.e. very good liquor) which he was willing to sell at the very reasonable price of $57 per case. Moran quickly agreed and told the hijacker to meet him at the garage at 10:30 the following morning.

The Ruse Worked
On the morning of February 14, 1929, the lookouts (Harry and Phil Keywell) were watching carefully as the Moran gang assembled at the garage. Around 10:30, the lookouts recognized a man heading to the garage as "Bugs" Moran. The lookouts told the gunmen; the gunmen climbed into the stolen police car.
When the stolen police car reached the garage, the four gunmen (Fred "Killer" Burke, John Scalise, Albert Anselmi, and Joseph Lolordo) jumped out. (Some reports say there were five gunmen.)

Two of the gunmen were dressed in police uniforms. When the gunmen rushed into the garage, the seven men inside saw the uniforms and thought it was a routine police raid. Continuing to believe the gunmen to be police officers, all seven men peacefully did as they were told. They lined up, faced the wall, and allowed the gunmen to remove their weapons.

Opened Fire With Machine Guns
The gunmen then opened fire, using two Tommy guns, a sawed-off shotgun, and a .45. The killing was fast and bloody. Each of the seven victims received at least 15 bullets, mostly in the head and torso.
The gunmen then left the garage. As they exited, neighbors who had heard the rat-tat-tat of the submachine gun, looked out their windows and saw two (or three, depending on reports) policemen walking behind two men dressed in civilian clothes with their hands up.

The neighbors assumed that the police had staged a raid and were arresting two men. After the massacre was discovered, many continued to believe for several weeks that the police were responsible.
Moran Escaped Harm
Six of the victims died in the garage; Frank Gusenberg was taken to a hospital but died three hours later, refusing to name who was responsible.
Though the plan had been carefully crafted, one major problem occurred. The man that the lookouts had identified as Moran was really Albert Weinshank. "Bugs" Moran, the main target for the assassination, was arriving a couple minutes late to the 10:30 a.m. meeting when he noticed a police car outside the garage. Thinking it was a police raid, Moran stayed away from the building, unknowingly saving his life.
The Blonde Alibi
The massacre that took seven lives that St. Valentine's Day in 1929 made newspaper headlines across the country. The country was shocked at the brutality of the killings. Police tried desperately to determine who was responsible.
Al Capone had an air-tight alibi because he had been called in for questioning by the Dade County solicitor in Miami during the time of the massacre. "Machine Gun" McGurn had what became called a "blonde alibi" -- he had been at a hotel with his blonde girlfriend from 9 p.m. on February 13 through 3 p.m. on February 14. Fred Burke was arrested by police in March 1931 but was charged with the December 1929 murder of a police officer and sentenced to life in prison for that crime.
This was one of the first major crimes that the science of ballistics was used; however no one was ever tried or convicted for the murders of the St. Valentine's Day Massacre. Though the police never had enough evidence to convict Al Capone, the public knew he was responsible. In addition to making Capone a national celebrity, the St. Valentine's Day Massacre brought Capone to the attention of the federal government.

The Whoopla on Whitney

2012-02-13T06:44:00.000-06:00

Do not get me wrong here, I recognize a good voice when I hear it, and I have a strong love for music, and Whitney Houston who did die this week had a great set of vocal chords, so I understood the first day of headlines, of face book comments, of Whoopla over an early exit, But not a 2nd day, or a 3RD day of it, this is not a public wake, she contributed to her lifestyle and wherever it took her on that road.

There is so much more that the news media could concentrate on, there are other stories, events, happenings that go unreported due to a Whitney who somehow couldn't value what had been placed in front of her.

And so somethings I do not get, I will never get.

Dicky 2-13

2012-02-13T06:32:00.000-06:00

I had a favorite cousin who played us Buddy Holly,
he and Sis taught us how to dance to rock n roll,

I had a favorite cousin he taught me how to barb
with words as he walked away from his mother Marge,

I had a favorite cousin, who'd show up unexpectedly at our house
he'd call my mother "Irish" and loved us with his heart

I had a favorite cousin, he'd make me laugh to tears,
his rhetoric continued for oh so many years.

Our birthdays but a day apart, he'd called me year after year,
yes they were drunk and 3am, but still made my eyes tear.

I had a favorite cousin whose prostate gained him pain,
he called to say a sweet goodbye & told me to behave.

I had a favorite cousin, and still remember his day,
I don't think that would ever stop just because he went away.

End Game

2012-02-12T16:15:00.000-06:00

In conclusion, it was really all about character, scruples, values, the simple things, the love in our lives that is so simple in real time and yet so complicated by human expectations.

I end my game exactly in heart as I started it, my head is still clear enough for that.

If others wanted to change, over think it, so be it, I only want more time, more days, and another chance to watch the sunrise.

And that is good enough for this girl.

Sunshine

Finding soul, finding heart

2012-02-10T03:32:00.001-06:00

"When was the last time, you ever saw the sunrise?" Not enough, I seemed to have missed them lately, poor timing, or not tuned in, or all.

Days bring details at work, work seems to be consuming, chipping away at the edge you sometimes possess. The edge I refer to is a rather three D perspective of being able to see it all, and therefore any pieces lacking, therefore being able to anticipate what's needed before someone else would even know it was missing.
The edge I speak of to me really is a 3D view in real time used in days of old when out with the girlfriends for dinner I was 3D'ed, and could hear it all, read the room, our table, multiple conversations, and all the while I was soulfully floating listening to the piano player and tunes from the prior 3-4 decades float into the atmosphere bringing tons of memories out of the closet as he played his music.

I came to the conclusion that I liked piano bars, and restaurants with piano bars in them, it was good for the soul, a healing effect, a lovely component to feed the soul. Was I even at the table with them, mmmm, not as much as they thought, I was abstracted so many places transformed by the music you couldn't have caught all my fragments with a butterfly net, and the above is the best description I can come up with to define a soul, which is governed by head and heart. Music feeds the soul, always.

Now they'd pull me back down into the table eventually, some problem in a life there, asking opinions for a solution, I was brutally clear cut grasping a bottom line they didn't expect out of someone so quiet, some mix of myself and learned spousal behavior thrown onto the table for them grasp, eventually they came to count on me for these answers. Part of this was from the 3D moments, and part of it came from having an "Edge", not all people have, just as so many don't even have common sense, but I do believe the "Edge" derived itself from instinct, my instincts were developed strongly from growing up in Chicago, school, work, the streets, buses, beaches packed in summer, being chased multiple times by someone or something, morons in cars trying to coax a child, a rabid dog encountered, and cruel children, how the hell could you grow up in there and not come out it with great instincts? I always figured only New Yorkers could top it.

Somewhere during all these dinners of 10 years, almost every Friday evening we gathered, same group on occasion mixed with a straggler acquaintance someone dragged into the mix, music, people problems, humorous evenings somewhere in there I found a middle aged women who had much soul left, who had a side softened by music, but she emerged much harder than anyone in her family would suspect....
well maybe her mother saw the change, this harder self, maybe she'd morphed at some point in life too, so it served it's purpose well, it brought to the front someone with so many components she'd forgotten through the years had even existed, and in doing so made her stronger for all the next chapters that would play out, some bringing heavy duty days she couldn't have faced well the old way.

Sometimes you need to take the time, and realign yourself, listen to music, go to an art museum, read something heartwarming, feed the soul, and your heart will re-emerge, you might even get your edge back. We need to do more of that. Time out and take a step back....and see, really see.

The box within the maze

2012-02-06T06:43:00.000-06:00

There is a box in the maze, the box holds opinions, emotions, solutions or possible options for them.
She's always drawn the maze as her doodle, and yet the box was always at the core the maze, wasn't it?
I think she could have gotten out of the maze, the problem had always been getting out of the box, once freed from the box finding her way out of the maze would have been easy street, no the box was the damn problem.
The box has so much going on within it that it constantly sidetracked her from progressing, all those opinions most of which have been held silently inside tucked into the corners of the box, the emotions triggered by days as they shaped or by others who frequented the box, constant attentions and little details to be worked, left her with solutions to 7 things when she started with 1, now do this daily and you'll soon understand why it's so hard to get freed of the box.
Time becomes an important ingredient, time can give so much. Discipline, is sorely lacking inside the box, chaos should be gotten under reign, discipline's invoked, self discipline which have corrupted.
So we head back into the box to re-assess, notice it has the word ass in it....must have been intentional.

The diversity of facebook, pros/cons

2012-02-05T06:23:00.000-06:00

The odd thing is one person will post humorous posts, someone musical favorites, someone else 28 weeks pregnant and a pic, someone else posts pictures of children malformed over and over again like that's all they can be drawn to, someone is on a dog campaign in Romania trying to get dogs freed to other countries and on occasion they post pictures of starved dogs, run over dogs, you can click on an item to remove it from you site.
Then there are the gamers who only go online to play their favorite games such as farmville, or mafia wars, others will post what they're doing in their day, or special landmarks of their family. Other post seeking prayers from all their friends for ill family members, some of them have an awful lot of sickness in their family, young teachers posting that the schools morning for one of the students who was in the townhouse where some crazy 1/2 relative shot them all and set the place on fire before he went home to off himself.
A wide range of emotions are released on facebook, sometimes it tugs my heart, and others I just don't understand, nephews through marriage posting lewd crap will either get unfriended or reproached whether they like the scolding or not.
It's a community of acquaintances, family, friends, co-workers, all piles into one streamlined posting after posting, depending upon who you let into your facebook page.

Sometimes music captures the heart

2012-02-05T06:09:00.000-06:00

http://www.youtube.com/watch?v=UrIiLvg58SY

Conversations never had .........................................proes 2012

2012-02-04T07:04:00.000-06:00

There was a time and place as all of us played out,
the right turns and the left merge slowly brought about,
a thing that I have labeled conversations never had,
it is the place minds wander when they seek to re-convey
all the words we've never spoken on important matters in our day.

Too often life will lead us to shrug off, or walk away,
leave words hanging on the atmosphere, these things we never say.
No matter that we think them, the words could fill our souls,
but when left unsaid some part remains dead,
hidden in conversations we never had.

So live your life the truest, say what's on your mind,
there will be no backpedaling, recaptures live in film,
you only pass this way but once, today is what you have.

Depression through News

2012-02-04T06:44:00.000-06:00

So many people, so little time
varied opinions, projected through polls.
Progress unhinged by these gravitating souls,
meaning no harm, but not stopping to think,
the boats turned around now, and ready to sink.

One percent protected for hundreds of years,
the balance of Americans sink under their tears,
In separating from England and all it's oppressions,
the laws that were placed here pontificated depressions.

The voter's no patience,short memories,traded sides
No hope up ahead, American Dreams Died.
Somewhere up ahead Mad Max really looms,
The varied opinions and Reptilians brought our doom.

A Beautiful Song by Mary Travers:

2012-02-04T06:01:00.000-06:00

"When was the last time, you ever saw the sunrise?"

http://www.youtube.com/watch?v=zTEdhMwXiM4&feature=related

What's in a month, I love February

2012-02-02T07:44:00.000-06:00

First memories are triggered with the entrance of February, remembering Dad rolling in the door with flowers or Fannie Mae's for Ma, and little heart shaped boxes for us, stories of a ground hog that could predict how long we'd be waiting for spring to come so we could start playing in our dirt yard, My own birthday and presents from my Auntie Mame, my little precious dolls, and buggy that would used to house my worms excavated from the damp earth, how I loved them, nothing was as good as a day of earthworm mining. Little children exchanging valentine's cards even including the kids that had cootie's, and the school mortification of bringing a birthday treat for the class whereby way to many bullies tried to give birthday spankings, one year resulting in doctors office visit to remove pebbles from my hand and abrasions from sliding out onto Bryn Mawr as I ran from them.
Picking a wedding date and all it brought life, our son being born, and all these years of growing and loving, each stage was enjoyed.
Drive's home bring me sunsets, and amethyst skies, closer to spring now, and all that new life, for me February is a beautiful word.

An Endless Circle

2012-01-28T20:56:00.000-06:00

It was the most beautiful symbol, as symbols are of great beauty to their beholder, it symbolized an endless depth, with horizons vast and journeys far, and the circle of life and love and home and soul continued on it's days.

It wasn't square with corners or oval to lower dynamics, it was round to keep it flowing, with light to keep it brightened. The endless circle has traveled far, the warmth and care still living, the souls they're ever changing, but always circle home.

So when it comes to the endless circle, that's what was intended.

Our Political Debates or Follies, an American Horror Story

2012-01-28T20:34:00.000-06:00

Our political process has grown obsolete, constant deadlocks, constant thwarts on any real progress that could have made.
In 2008 when our great country began to sink into the nightmare of 2009 the Republicans had held office hostage via Bush and Chenney, no signs of respect intended here, so no title preface is being used, God what they allowed to happen to our country still echoes out, and Geitner, do not forget the ever lovely role of Mr. Geitner who was aware of all the wrong doings and swept them under the money rug to conceal them (wall Street and the Big Banks & the Mortgage Collapsing Market as the got caught selling off bad loans in big bundle's to the European Markets and our own American Markets, this would be called "bad paper" in any other financial realm, but of course Mr. Geitner was made aware so he could do damage control, and the Presidential candidates were pulled into the loop so they'd have some inkling of what real nightmare they were trying to get elected to, McCain & O'Bama were kept in the loop as the first stage of bailouts was announced and implemented, President O'Bama took over, he being from the Democratic Party. He had some Democratic backing from the house and Congress, but another election 2 years into his new powers took the Democratic Congress, and that was replaced by a predominant Republican house, and progress has been deadlocked ever since.
I can't even describe what a fiasco the Republicans have invoked the past two years, every topic to be implemented as a bill for their Congressional vote they have bastardized, torn to shreds, disemboweled, they've spit in the face of the taxpayers, they spit in their peers faces, and most definitely have waged a personal war with the President, not respect shown to the office, and all the blame they direct his way, when it was truly the two Glamor Republican boneheads Bush and Chenney who set this horrid American Collapse in motion, and the joke on us was they went un-investigated and un-prosecuted from Crimes Against their own Country.

Now we have more Republicans running for office of the President of the United States/or what's left of her, and they bicker amongst themselves, throw mud, and act like children out at a recess, dragging each others skeletons out of the proverbial closet, it is so upsetting and disgusting of a display, "WHY WOULD YOU WANT THEM TO BE THE LEADER OF YOUR COUNTRY?

Is there really that much prejudice left that we'd let boneheads take over when we actually have a good person in there that is just lacking cooperation? Where does insanity really start?

Oscar and my son

2012-01-28T08:38:00.000-06:00

“Man is least himself when he talks in his own person. Give him a mask, and he will tell you the truth.” - Oscar Wilde

One of our favorite's for quotes is Oscar Wilde. But when I see this one I think of a little boy who so, love to don a mask, and in he would travel to his Grandpa and Grandma to sit round their dining room table and ask his great questions for truths.
This included the mask from Robin of Batman & Robin, Spider Man's mask, some others, the game itself and the mood always remained the same. As if wearing the mask somehow made the truths answered or the questions asked more etched in the universe.

Don't wear all have at least one mask? Is it to protect us from the answer or the question?

Defining Moments

2012-01-28T05:20:00.000-06:00

"When was the last time, you ever saw the sunrise?"

Defining moments in life come in all shapes and sizes, they are the good times, bad times, a moment that just stands out in time in it's own frame.

They could include a man bringing a Christmas tree home on a sled in a blizzard from a miles away (there and back) as his transmission had gone out on the car., or a blizzard of 67 and the fun you had with your brothers in that white world of snow up to your waist, how many times did your parents tell your brothers " Don't lose Chicky".
They might include scary moments as a child eluding a bad guy in a car, or being chased by non friend entities who only wanted to hurt you, thank God the brothers taught me how to jump fences, many such adventures would follow that first 17 years.

So what defines us, it's all those moments stacked up. That's what really make each one tick a different way, isn't it?

Hospitals with people saying it would be ok, only to pop back in with disastrous news, oh yeah I have faith in you all.
People popping into your life, only to leave you standing on some type of unstable Wisconsin Dells Rock, those wild looking cliffs and overhangs like Wily Coyote and the Road runner played through, the dreams at the bottom, soul temporarily dead.

Some of our characters for life are pulled from us in a moment, some remain and play out their own roles, but with so many defining moments, still shaping and shifting who you will end up as.

So thank God for the soul within, some call the inner child, who watched and participated in the long haul, the one who's stronger than any one would have suspected, that little voice who constantly re-assessed and reasoned out how to keep progressing on this path we call life.

Each one of us is built and motivated by those defining moments in time, it could only have been as simple as going down to the Lake to watch the sunrise when you were young and twenty with the love of your life.

When was the last time you saw the sunrise? Was it a defining moment?

Possible problems with haemodialysis

2012-01-25T19:19:00.002-06:00

Possible problems with haemodialysis

Haemodialysis is a much more intensive treatment than peritoneal dialysis: all the dialysis is condensed into a few sessions a week. Many potential problems with haemodialysis are due to this fact.

Rapid changes in blood pressure
The speed at which water is removed from the blood during haemodialysis may cause a sharp drop in blood pressure. This makes some patients feel unwell, either during or after the treatment session. Fainting, vomiting, cramps, temporary loss of vision, chest pain, irritability, and fatigue can occur.

Fluid overload
Haemodialysis patients sometimes develop a condition called fluid overload between dialysis sessions. Excess water collects under the skin at the ankles and elsewhere in the body, including the lungs.

To avoid fluid overload, haemodialysis patients should restrict the amount of fluid they drink. This also helps avoid the problems caused by rapid physical changes during haemodialysis.

Restrictions on fluid intake for haemodialysis patients are stricter than those for peritoneal dialysis patients.

Hypaerkalaemia
Hyerkalaemia is caused by too much potassium in the blood and can interfere with the heart's rhythm. Severe hyperkalaemia can cause the heart to stop.

Most haemodialysis patients are asked to restrict their intake of foods that contain a lot of potassium.

Loss of independence
Although patients on haemodialysis have "days off", some feel that having to travel to the renal unit or self-care unit several times a week, every week of the year, is a burden.

Home haemodialysis and peritoneal dialysis patients do not have this burden since they are treated at home.

Blood-borne viruses
Some patients have concerns about contracting blood-borne viruses, such as hepatitis B or C, or HIV. All renal units take measures to protect patients from this risk. If you are concerned, you should discuss your concerns with the medical team.

Amyloidosis
Renal bone disease is not the only cause of bone pain in patients with kidney failure. Bone pain can also be caused by a condition called dialysis amyloidosis.

This condition can develop 10 years or so after the start of dialysis. It is caused by the build up of a protein called amyloid, which is not easily removed by dialysis. It is deposited in joints all over the body, leading to joint and bone pain. At present there is no effective treatment for this condition. It can be halted, to an extent, by transplantation.

Other potential problems with haemodialysis, described below, are related to access.

Fistulas
Not all fistulas work perfectly. Some never develop into a vein that is large enough. Some work well for years and then suddenly stop. In either case, a new fistula (or sometimes a graft) will have to be made in another part of the body. Only a limited number of veins can be made into a fistula. Caring for the fistula is important.

Access can be a particular problem for patients with diabetes or for children since the blood vessels are often very narrow.

HD catheters
HD catheters may stop working because they become blocked by a blood clot. If this happens, they will have to be replaced. Only a limited number of veins are suitable for catheter insertion.

Needles
If access is achieved via a fistula or graft, it is necessary to insert needles at the start of each dialysis session. Even with a local anesthetic, some patients find this painful.

Bleeding
Some patients may have problems with bleeding from the fistula either during or after dialysis. There are now special bandages available which can help stop the bleeding more quickly. Most renal units can supply these or advise where they can be obtained.

Infections
There is a risk of picking up an infection during a dialysis session. Infections can usually be treated with antibiotics. Strict attention to hygiene during the preparation of the dialysis machine and access can help prevent infection.

Exit site infections may occur where a dialysis catheter comes out of the skin. The area around the exit site becomes red and inflamed. The infection can "tunnel" inside the body, following the route of the catheter. Most exit site infections respond well to antibiotics.

Increasing arteriovenous fistulas in hemodialysis patients

2012-01-25T19:15:00.004-06:00

Perspectives in Renal Medicine

Kidney International (2002) 62, 1109–1124; doi:10.1111/j.1523-1755.2002.kid551.x
Increasing arteriovenous fistulas in hemodialysis patients: Problems and solutions

Michael Allon and Michelle L Robbin

Division of Nephrology, Department of Medicine, and Department of Radiology, Division of Ultrasound, University of Alabama at Birmingham, Birmingham, Alabama, USA

Correspondence: Michael Allon, M.D., Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, 1900 University Blvd, S. THT 647, Birmingham, Alabama 35294, USA. E-mail: mallon@nrtc.uab.edu

Received 7 January 2002; Revised 26 March 2002; Accepted 10 April 2002.
Top of page
Abstract

Increasing arteriovenous fistulas in hemodialysis patients: Problems and solutions. National guidelines promote increasing the prevalence of fistula use among hemodialysis patients. The prevalence of fistulas among hemodialysis patients reflects both national, regional, and local practice differences as well as patient-specific demographic and clinical factors. Increasing fistula prevalence requires increasing fistula placement, improving maturation of new fistulas, and enhancing long-term patency of mature fistulas for dialysis. Whether a patient receives a fistula depends on several factors: timing of referral for dialysis and vascular access, type of fistula placed, patient demographics, preference of the nephrologist, surgeon, and dialysis nurses, and vascular anatomy of the patient. Whether the placed fistula is useable for dialysis depends on additional factors, including adequacy of vessels, surgeon's experience, patient demographics, nursing skills, minimal acceptable dialysis blood flow, and attempts to revise immature fistulas. Whether a mature fistula achieves long-term patency depends on the ability to prevent and correct thrombosis. An optimal outcome is likely when there is (1) a multidisciplinary team approach to vascular access; (2) consensus about the goals among all interested parties (nephrologists, surgeons, radiologists, dialysis nurses, and patients); (3) early referral for placement of vascular access; (4) restriction of vascular access procedures to surgeons with demonstrable interest and experience; (5) routine, preoperative mapping of the patient's arteries and veins; (6) close, ongoing communication among the involved parties; and (7) prospective tracking of outcomes with continuous quality assessment. Implementing these measures is likely to increase the prevalence of fistulas in any given dialysis unit. However, differences among dialysis units are likely to persist because of differences in gender, race, and co-morbidity mix of the patient population.
Keywords:

preoperative vascular mapping, graft placement, hemodialysis, end-stage renal disease, thrombosis, dialysis blood flow, vascular access, A-V fistula

Vascular access procedures and complications account for over 20% of hospitalizations of dialysis patients in the United States and cost about $1 billion annually1,2. In an effort to improve vascular access outcomes the National Kidney Foundation published the Dialysis Outcome Quality Initiative (DOQI) guidelines in 1997, a set of evidence-based and opinion-based guidelines regarding the optimal management of vascular access3. The DOQI guidelines have stimulated a large body of epidemiologic and clinical studies on vascular access, thereby expanding our understanding of this important topic. One important DOQI guideline has urged nephrologists to increase the number of patients dialyzing with arteriovenous (A-V) fistulas, rather than grafts. The present review summarizes recent clinical research that helps us understand how to achieve this important goal.
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WHAT IS THE RATIONALE FOR INCREASING FISTULA PLACEMENT?

The relative merits of A-V fistulas and grafts have been a subject of ongoing investigation and debate for many years. Thirty years ago, patient selection for dialysis was relatively stringent, and most patients were young, non-diabetic men with minimal co-morbidity Table 1. Within this select population, the arteries and veins were generally well preserved and permitted construction of native A-V fistulas in the wrist. The expectation was that the vast majority of fistulas placed would mature adequately to be used for dialysis, and subsequently remain patent and useable for dialysis for many years with minimal intervention. In addition, up until the mid-1980s the median dialysis blood flow in the United States was about 250 mL/min4, such that even relatively small diameter fistulas could deliver the desired flows.
Table 1 - Hemodialysis patient characteristics in the United States (1967 and 1999) and in Europe (1999).
Table 1 - Hemodialysis patient characteristics in the United States (1967 and 1999) and in Europe (1999) - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the authorFull table

In recent years, as a result of more liberal selection criteria, the chronic dialysis population has become substantially older, more likely to be female and diabetic, and has higher co-morbidity, including extensive atherosclerotic vascular disease Table 1. Many of these patients appear to have poor vessels for construction of native fistulas. Concurrently, increased emphasis on dialysis adequacy (Kt/V) has led to the recognition that higher blood flows can improve urea clearance, and thereby permit delivery of adequate dialysis to larger patients without entailing substantial increases in dialysis times. These considerations have led to increased utilization of A-V grafts and decreased use of A-V fistulas. By the mid-1990s only 20% of patients in the United States were dialyzing with fistulas5.

With the growing use of A-V grafts, it became evident that the prosthetic vascular access is prone to an alarming frequency of thrombosis6. Further investigation led to the observation that graft thrombosis usually arises from progressive stenosis at the venous anastomosis or the draining vein, and that prophylactic angioplasty of stenotic lesions decreases the frequency of graft thrombosis substantially7,8,9,10,11. Recognition of the value of elective angioplasty led to considerable research on monitoring methods for detection of hemodynamically significant graft stenosis2. Nonetheless, it became clear that graft stenosis is a frequent and recurrent process, and that monitoring and intervention to prevent graft thrombosis is costly and labor intensive2.

Arteriovenous fistulas once again came into favor due to their lower frequency of stenosis, thrombosis, and infection, as compared to A-V grafts. In this context, the DOQI vascular access guidelines advocated intensive efforts to increase the prevalence of fistula use among dialysis patients3. These guidelines recommend attempting fistula placement in at least 50% of patients, with A-V grafts being reserved for patients whose vascular anatomy does not permit construction of a native A-V fistula. DOQI guidelines predict that such a strategy will result in 40% of prevalent patients dialyzing with a fistula.

A major hurdle in achieving this goal is the high frequency of new A-V fistulas that are never useable for dialysis (primary failures) either due to early thrombosis or due to lack of maturation. A deliberate policy of placing A-V fistulas in the majority of dialysis patients, many of whom have marginal vessels, necessarily increases the frequency of primary failure. Whereas studies from 20 to 25 years ago observed a primary fistula failure rate of about 10%, more recent investigations have typically reported a 20 to 50% primary failure rate Table 2. The primary (intervention-free) survival of fistulas at one year was better than that of grafts in some studies, but not in others Table 2. These comparisons are often misleading, because some investigators have specifically excluded fistulas that never matured, whereas others have included primary failures, when calculating primary patency. Given the higher rates of non-maturation of fistulas as compared with grafts, the two types of calculations lead to different conclusions. Thus, for example, Oliver et al reported that the primary patency of fistulas was superior to that of grafts, when primary failures were excluded12. However, when primary failures were included, the primary patency of fistulas and grafts was comparable during the initial year.
Table 2 - Short-term outcomes of fistulas.
Table 2 - Short-term outcomes of fistulas - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the authorFull table

Similarly, studies comparing the cumulative survival (time from access placement to permanent failure) at one year of fistulas and grafts have yielded contradictory results Table 3. Again, these discrepancies can be attributed to discrepancies in the primary failure rates of fistulas as compared with grafts, as well as whether primary access failures were included in the calculations of access survival. Oliver et al reported that, when primary failures were excluded, the cumulative patency of fistulas was superior to that of grafts12. However, when primary failures were included, the cumulative patency of fistulas and grafts was comparable at one year Figure 1. The equivalent outcome occurred because the higher primary failure rate of fistulas was offset by the lower rate of subsequent failures. Similar observations on the relative short- and long-term outcomes of fistulas and grafts have been reported by our institution13.
Figure 1.
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Failure-free survival (cumulative patency) of brachiobasilic fistulas (dotted line), brachiocephalic fistulas (dashed line), and upper arm grafts (solid line) excluding (A) and including primary failure (B). When primary failures are excluded, survival of brachiocephalic and brachiobasilic fistulas are comparable to each other, and both are better than for grafts. When primary failures are included, the survival rates for all three types of vascular access are comparable. (Reproduced with permission from the International Society of Nephrology12.)
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Table 3 - Long-term outcomes of arteriovenous (A-V) fistulas versus grafts.
Table 3 - Long-term outcomes of arteriovenous (A-V) fistulas versus grafts - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the authorFull table

Despite the comparable cumulative survival of fistulas and grafts, the major advantage of fistulas over grafts is the lower frequency of interventions and complications, once they mature. Maintaining long-term graft patency requires a 2.4- to 7.1-fold higher frequency of salvage procedures (angioplasty, thrombectomy, and surgical revision; Table 3). Moreover, access infections occur substantially more frequently in grafts as compared to fistulas Table 3. In the short-term, placing a fistula requires a greater investment, due to the higher primary failure rate and much longer time to maturation. The long-term payoff, however, is prolonged patency with far fewer interventions, complications, and expenditures.

A major clinical challenge is to optimize the approach to constructing A-V fistulas, so as to maximize the proportion of patients receiving a fistula while minimizing the proportion of fistulas that never mature. The goal of the present review is to examine critically the reasons underlying the discrepancy between the goals and reality. Specifically, we will examine the clinical and logistic obstacles to increasing the prevalence of fistulas among hemodialysis patients. We will also address specific measures that have been documented to improve vascular access outcomes at selected institutions.
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WHAT FACTORS AFFECT FISTULA PREVALENCE IN DIALYSIS PATIENTS?
Geographic variations

Practice patterns can have a major impact on the prevalence of patients dialyzing with fistulas. In a landmark study Hirth et al reported substantial geographic variations in the prevalence of fistulas among new dialysis patients within the United States, ranging from a high of 77% in New England to a low of 15% in the Southeast14. Similarly, analysis of a cohort of 1824 patients enrolled in the HEMO Study at 45 American dialysis units found substantial geographic variations15. The prevalence of fistulas was 45.3% in the Northeast, but only 30.6% in the Southeast. In both reports, these geographic differences persisted even after adjustment for multiple demographic factors and co-morbid conditions. Variations in the type of vascular access are also reflected in the 2000 Annual Report of ESRD Clinical Performance Measures16. During the fourth quarter of 1999, 27% of U.S hemodialysis patients were using fistulas. The prevalence of fistulas varied greatly among the 18 networks, ranging from a low of 15% to a high of 47%.

There are also substantial differences among countries. The Dialysis Outcomes and Practice Patterns Study (DOPPS)17 reported that only 24% of U.S. patients were dialyzing with fistulas, as compared with 80% among dialysis patients in five European countries (Germany, France, Italy, Britain, and Spain)18. Lower co-morbidity among European dialysis patients Table 1 may account for some of the difference. However, it is likely that variations in practice patterns also play a major role.

Variations in fistula prevalence are not limited to comparisons among countries or large geographic regions. They are also evident when one compares individual dialysis units within a single metropolitan area Figure 215. For example, the prevalence of fistulas at five dialysis units in one metropolitan area (Center 11) was 28.6, 43.8, 50.0, 58.8, and 76.7%, respectively. Similarly, the DOPPS Study reported that fistula use varied from 0 to 87% among individual American dialysis units, and from 39 to 100% among individual European units18. Such differences may reflect the individual preferences or skill level of the surgeons, nephrologists, and dialysis unit staff. One study reported that in 35% of U.S. dialysis units the dialysis staff preferred grafts over fistulas19.
Figure 2.
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Frequency of fistula use among the hemodialysis units in the HEMO Study. The dialysis units are sorted with the 15 clinical centers with which they are affiliated. The dialysis units in a given clinical center are located in a single metropolitan area. There are large variations in the prevalence of fistula use among individual dialysis units. (Reproduced with permission from the International Society of Nephrology15.)
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Patient factors

Several demographic and clinical factors have been associated with a lower prevalence of fistulas, even after adjustment for geographic region and dialysis unit. Numerous studies have reported that female patients are much less likely than males to dialyze with a fistula14,15,18,20,21,22,23. The 2000 Annual Report of ESRD Clinical Performance Measures found that nationwide, the prevalence of fistulas among women was only 18%, as compared to 35% in men Figure 316. This discrepancy between the genders was observed in each of the 18 U.S. networks.
Figure 3.
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Percent of U.S. patients dialyzing with fistulas in October to December 1999, sorted by patient gender and dialysis network. Symbols are: (filled square) female patients; (square) male patients. Overall fistula prevalence varies greatly among networks, but in each of the 18 networks, fistula use is lower among women than men. (Adapted from16.)
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Similarly, a number of recent studies have observed a lower prevalence of fistulas used for dialysis among blacks than whites12,15,23,24. Hirth et al did not observe a difference in the frequency of fistulas between black and white dialysis patients14. However, they reported the type of vascular access present in the patient's arm 30 days after initiation of dialysis, regardless of whether the access was actually useable for dialysis. It is unclear whether the prevalence of useable fistulas differed among races. In a recent nationwide survey, fistulas were being used in 23% of black patients, as compared with 29% of whites Figure 416. Examination of individual U.S. networks revealed a lower prevalence of fistulas in blacks than whites in 15 of the 18 networks. Fistula prevalence was equivalent or slightly higher in blacks than whites in only two networks. A comparison was not possible in one network, because its black population was too small to perform a valid statistical comparison. A recent investigation from the United Kingdom also observed that black patients were significantly less likely to dialyze with a fistula than were whites (abstract; Fan et al, J Am Soc Nephrol 12:288A, 2001).
Figure 4.
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Percent of U.S. patients dialyzing with fistulas in October to December 1999, sorted by patient race and dialysis network. Symbols are: (filled square) black patients; (square) white patients. Overall fistula prevalence varies greatly among networks, but in nearly each individual network, fistula use is lower among blacks than whites. Network 15 had too few black patients to be included in the analysis. (Adapted from16.)
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Age is an additional independent factor associated with the prevalence of fistulas14,15,18,23,24. Nationwide, the prevalence of fistulas among U.S. hemodialysis patients was 35% in adult patients under age 45, 31% in patients aged 45 to 54 years, 26% in patients ages 65 to 74, and 23% among patients 75 or older16. The inverse relationship between age and frequency of fistula use was evident in each of the 18 networks.

Diabetes has been associated with a lower prevalence of fistulas in some studies14,18,24, but not in others15,23. Nationwide, only 22% of U.S. diabetic hemodialysis patients were using fistulas, as compared with 30% of non-diabetic patients16. There is controversy as to whether diabetes is an independent risk factor for lower fistula prevalence14, or whether it is a marker for other associated clinical or co-morbid conditions, such as female gender, older age, black race, obesity, and presence of peripheral vascular disease15.

Other factors that have been associated with a lower fistula prevalence include presence of peripheral vascular disease14,15,18,21, obesity15,18,24, and lower socioeconomic status14.
Practice patterns

Successful, long-term use of a fistula for dialysis requires overcoming at least four hurdles. First, the surgeon must be able and willing to place an A-V fistula. Second, the newly constructed fistula must mature sufficiently to be cannulated reproducibly with large-bore needles and deliver an acceptable dialysis blood flow. Third, the dialysis staff must be proficient in cannulation of fistulas. Finally, the mature fistula must remain patent with minimal requirements for further interventions. Problems occurring at each of these levels can have a cumulative negative effect on the overall prevalence of patients dialyzing with fistulas. Increasing fistula prevalence requires a clear understanding of the factors contributing to the problem, and aggressive efforts to overcome these roadblocks. The next few sections will address the specific variables that determine whether a patient receives a fistula, whether the fistula matures, and whether it achieves long-term patency for dialysis.
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FACTORS AFFECTING FISTULA PLACEMENT
Timing of fistula placement

The mean maturation time of new A-V fistulas is about two to four months12,13,25,26. Moreover, patients whose fistula fails to mature adequately to be used for dialysis require subsequent interventions to promote fistula maturation, or alternatively, construction of another vascular access. If the patient is already on dialysis, fistula placement entails prolonged hemodialysis with a temporary dialysis catheter with all its attendant complications, including poor blood flows, frequent thrombosis or malfunction, and life-threatening bacteremia27. Clearly, these issues can be avoided when the fistula has been constructed in a timely fashion in pre-dialysis patients, so that it is ready for use prior to the need for maintenance dialysis. In this regard, the DOQI guidelines recommend referring patients for fistula placement when the serum creatinine is>4 mg/dL or the creatinine clearance <25 mL/min3. At initiation of dialysis, 66% of U.S patients use a catheter, 22% use a graft, and only 12% use a fistula. Sixty days after initiation of dialysis, 32% still dialyze with a catheter, 49% with a graft, and 19% with a fistula. Of those patients who started dialysis with a catheter, but were dialyzing with a permanent access at 60 days, only 25% were using a fistula, whereas 75% had a graft24. Despite the DOQI guidelines, many patients with chronic kidney disease are not referred to a nephrologist until their renal failure is very advanced. Even among those patients with early referral (at least 4 months before initiation of dialysis), a substantial proportion still do not get a permanent vascular access prior to initiation of dialysis. Arora et al reported that a functioning permanent vascular access at initiation of dialysis is found in 40% of patients with early referral to a nephrologist, but only 4% of patients with late referral28. Moreover, the first vascular access is more likely to be a fistula than a graft in patients with an early referral than those referred late (45 vs. 31%)29. Similar observations have been reported from Europe. A recent French study noted that among patients with late referral, 73% initiated dialysis with a catheter, and only 12% with a fistula. In contrast, among patients with early referral, 29% initiated dialysis with a catheter, and 53% with a fistula30. At the time of initiation of dialysis, only 15% of U.S. patients use fistulas, as compared with 66% of European patients18. Differences in health coverage among countries may contribute to this discrepancy. Universal health coverage, which is common in most European countries, promotes comprehensive medical care and early referral to nephrologists and surgeons. In contrast, a substantial proportion of patients with chronic kidney disease in the U.S. do not qualify for health coverage until they initiate dialysis. Type of fistula placed The original type of fistula described was the radiocephalic fistula Figure 5, which involves a direct anastomosis of the radial artery and cephalic vein at the wrist31. Many patients without suitable vessels in the forearm may be good candidates for construction of a brachiocephalic fistula in the upper arm Figure 6. Because the cephalic vein is frequently cannulated in the antecubital space for phlebotomy, the resulting stenosis or thrombosis may preclude its use for construction of a fistula. The basilic vein, which runs deeper and is spared from phlebotomy, often has a large enough diameter to permit its use for fistula construction. However, its depth from the skin would preclude cannulation of a brachiobasilic fistula in the native position. To overcome this difficulty, the basilic vein can be dissected out and tunneled in the subcutaneous tissue of the anterior upper arm, easily accessible with a dialysis needle Figure 7. The invention of the transposed brachiobasilic fistula32 has further expanded the proportion of patients in whom construction of a native fistula is feasible. Finally, Polo et al recently described construction of a brachiocephalic jump graft fistula, whereby a short polytetrafluoroethylene (PTFE) segment is tunneled subcutaneously and anastomosed to the brachial artery and cephalic vein through two short skin incisions33. They reported a primary patency rate of 85% at one year, comparable to that observed with "pure" upper arm fistulas. Figure 5. Figure 5 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author Radiocephalic arteriovenous (A-V) fistula. Full figure and legend (62K) Figure 6. Figure 6 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author Brachiocephalic A-V fistula. Full figure and legend (48K) Figure 7. Figure 7 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author Brachiobasilic transposition A-V fistula. Full figure and legend (44K) The majority of dialysis patients can have a native fistula placed as their initial vascular access, provided that there is a willingness to consider all three types of fistulas, and to use preoperative vascular mapping to identify suitable vessels for their construction. Using objective sonographic criteria at our institution, a forearm (radiocephalic) fistula was placed in 48% of the patients. An additional 29% of the patients received an upper arm fistula (brachiocephalic or brachiobasilic), because a forearm fistula was not feasible. Thus, some type of native fistula could be constructed in 77% of patients, and only 23% received an A-V graft13. Miller et al could place a fistula in 76.5% of patients, including 42% in the forearm and 34.5% in the upper arm34. Dixon, Novak and Fangman reported that a fistula was possible as a primary access in 73% of patients (36% in the forearm and 37% in the upper arm), whereas only 27% required grafts26. Finally, Gibson et al were able to place an A-V fistula in 95% of patients (almost exclusively men)35. The likelihood of placing a secondary fistula among patients with at least one failed vascular access is considerably lower. Among this high-risk population, we found that a fistula was possible in only 39% (28% in the forearm and 11% in the upper arm), whereas 61% required a graft13. Patient demographics The likelihood of having a fistula placed can vary substantially among different patient subgroups Table 4. Numerous studies have reported that fistula placement is less frequent among women than men, and a few recent studies suggest that fistula placement is less likely among black than white patients. We found that female gender and black race were independent predictors of a lower likelihood of fistula placement. Using objective preoperative vascular measurements, a fistula could be placed in only 43% of black women, as compared with 92% of white men13. Table 4 - Likelihood of fistula (rather than graft) placement by clinical characteristics. Table 4 - Likelihood of fistula (rather than graft) placement by clinical characteristics - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the authorFull table Moreover, the initial fistula is more likely to be placed in the upper arm, rather the forearm, when the patient is female or black. Using objective preoperative sonographic criteria, we found that the initial fistula placement was in the upper arm in 64% of women, as compared with 36% of men. Similarly, fistula construction in the upper arm occurred in 54% of black patients, as compared with 34% of whites13. The effect of diabetic status on fistula placement is controversial. Whereas some studies have observed substantially lower fistula placement in diabetic, as compared with non-diabetic patients, other investigators have found little or no difference Table 4. Top of page FACTORS AFFECTING FISTULA MATURATION Adequacy of vessels and type of fistula Several changes are critical for the successful maturation of a new fistula36. First, it must dilate to a caliber large enough to be cannulated repeatedly with two large-bore dialysis needles. Second, the blood flow rate in the draining vein must increase sufficiently to accommodate the dialysis blood flow required to deliver adequate dialysis. To avoid vein collapse and recirculation, the access blood flow should exceed the desired dialysis blood flow by at least 100 mL/min. The mean dialysis blood flow varies substantially among countries: about 400 mL/min in the United States, 300 mL/min in Europe, and 200 mL/min in Japan (abstract; Dykstra et al, J Am Soc Nephrol 11:182A, 2000). All other factors being equal, this means that patients in Europe and Japan require substantially longer dialysis times than American dialysis patients to achieve comparable Kt/V values. These differences also mean that the definition of a mature fistula can vary among countries. A fistula that is deemed adequate in Japan or Europe when it delivers a dialysis blood flow of 200 to 300 mL/min may be considered inadequate in the United States. Using ultrasounds of fistulas obtained one to four months postoperatively, we observed that 40% of fistulas had an access flow rate <500 mL/min37. Clearly, a lower proportion of such fistulas would be deemed adequate for dialysis in the U.S., as compared with Europe or Japan. Third, the wall of the draining vein must hypertrophy sufficiently to seal after withdrawal of the dialysis needle. Finally, the fistula must be superficial enough for the landmarks to be appreciated and permit safe cannulation without infiltration. There is marked variation in the published literature regarding the definition of a "successful" fistula. The definitions have included presence of a thrill or bruit, ability to use the fistula for at least one dialysis session, or ability to use the fistula reproducibly for dialysis for at least one month with a dialysis blood flow>350 mL/min. Not surprisingly, the adequacy rate of fistulas is lower when a more stringent definition is used. Fistulas have a relatively high rate of primary failure Table 2, due to either early thrombosis or failure of the draining vein to dilate adequately to mature, that is, be cannulated and provide a reasonable dialysis blood flow reproducibly. In the absence of preoperative vascular mapping, the rate of primary failure may be substantially higher in forearm, as compared to upper arm fistulas. We reported a primary failure rate of 66% in forearm fistulas, as compared with 41% among upper arm fistulas25. Similarly, Hakaim, Nalbandian and Scott observed a 70% non-maturation rate for forearm fistulas among diabetic dialysis patients, as compared with 22% for upper arm fistulas38. Finally, Bender, Bruyninckx and Gerlag reported a primary one-year patency of 76% in forearm fistulas, as compared with 93% among upper arm fistulas39. A deliberate policy at one center of placing upper arm fistulas in preference to forearm fistulas resulted in a substantial increase (from 28 to 44%) in the prevalence of patients dialyzing with fistulas40.

There are contradictory conclusions as to whether the outcomes of secondary fistulas are different from those of primary fistulas. Using preoperative sonographic vascular mapping, we observed similar maturation rates of primary and secondary fistulas (53 vs. 54%)13. In contrast, Gibson et al reported that primary access failures were about 40% lower among primary than secondary fistulas35.

Several small European studies have observed a lower rate of early fistula thrombosis among patients treated with anti-platelet agents started preoperatively and continued for three to six weeks41. A large prospective, randomized study is clearly warranted to address this important clinical question.

Patients are frequently encouraged to perform regular hand exercise to promote maturation of a new fistula. There is no published research confirming the efficacy of this maneuver. The only study addressing this question failed to demonstrate a significant increase in A-V fistula flow during hand exercise in 40 patients with renal failure42.

Finally, the experience of the surgeon is also an important factor determining fistula outcome. Dixon, Novak and Fangman recently reported that fistula patency was worse if it was placed by an inexperienced surgeon (<12 access procedures) than if it was placed by an experienced surgeon26. Similarly, Pisoni et al found that a successful fistula was less likely if a surgery trainee performed or assisted in the access procedure18. These findings suggest that vascular access surgery should be restricted to surgeons with a strong interest and who perform a large number of access procedures. Patient demographics Fistula maturation varies substantially among different demographic groups. Prior to the use of preoperative vascular mapping, we found that new forearm fistulas were useable for dialysis in only 7% of women, 12% of elderly patients, and 20% of diabetics. In contrast, the respective maturation rates of upper arm fistulas for these patient subsets were 56%, 54%, and 48%, respectively25. When we began using objective sonographic vascular mapping to guide access placement, we discovered that vessels suitable for construction of a forearm fistula were less likely among women and blacks13. Once we began using routine preoperative vascular mapping to assist the surgeons in planning vascular access, we found no association between patient age, race, diabetic status or body mass index and the likelihood of fistula maturation. On stepwise logistic regression analysis, female sex was the only independent predictor of decreased likelihood of fistula maturation13. In agreement with these observations, Sedlacek et al observed similar maturation rates of fistulas among diabetic and non-diabetic patients43. Top of page FACTORS AFFECTING LONG-TERM PATENCY OF MATURE FISTULAS Type of fistula Dixon et al observed superior one-year primary patency (62 vs. 44%) and secondary patency (69 vs. 52%) of upper arm fistulas as compared with forearm fistulas26. The recent increase in utilization of brachiobasilic transposition fistulas has led to studies comparing their outcomes to those of A-V grafts and brachiocephalic fistulas. Coburn and Carney reported that the primary patency at one year of brachiobasilic fistulas was 90%, as compared with 70% of upper arm grafts20. Moreover, the grafts had a complication rate 2.5-fold higher than the fistulas. The primary failure (lack of maturation) rates are comparable for brachiobasilic and brachiocephalic fistulas: 21 vs. 22% in one study38, and 21 vs. 32% in a second report12. Recently, Oliver et al compared the survival of upper arm brachiocephalic fistulas, transposed brachiobasilic fistulas, and upper arm grafts at one institution12. Excluding primary failures, thrombosis-free survival at one year was 50% for grafts, 77% for brachiobasilic fistulas, and 93% for brachiocephalic fistulas. Thus, brachiobasilic fistulas were superior to synthetic grafts, but inferior to brachiocephalic fistulas. Excluding primary failures, the cumulative (assisted) survivals of brachiobasilic and brachiocephalic fistulas were comparable to each other, and superior to that of A-V grafts Figure 112. When primary failures were included, the cumulative survival was comparable for all three types of vascular access Figure 1. However, the intervention rates per access-year to achieve long-term patency were 2.4 for grafts, 0.7 for brachiobasilic fistulas, and 0.4 for brachiocephalic fistulas. The DOPPS Study reported that primary patency of fistulas was lower in the United States than in Europe (68 vs. 83%)18. The reason for this discrepancy remains to be elucidated, but possible explanations may include differences in patient co-morbidity or skill of the dialysis staff in fistula cannulation. In addition, the primary patency of fistulas was inferior among patients starting dialysis with a catheter, as compared with patients who initiated dialysis therapy with a mature fistula18. Patient demographics The primary patency (time from placement to first intervention) of fistulas varies among different patient subsets. Gibson et al reported that intervention-free survival of fistulas was clearly better than that of grafts for white men and younger men35. In contrast, the differences between the primary patencies of fistulas and grafts were not significant among black men or older men. Since this study was performed at a Veterans Hospital, the investigators were unable to address potential differences in fistula maturation between men and women. However, Astor et al reported that intervention-free survival was identical between fistulas and grafts among female dialysis patients44. Primary access survival was superior for fistulas among male patients, but this advantage was limited to men younger than 72 years of age. In agreement with these studies, Wolowczyk reported that fistula patency was substantially worse in women than in men45. Similarly, Gibson et al observed that the cumulative access survival (time from access placement to permanent failure) was better for fistulas than for grafts35. Once again, the differences were not uniform on subset analysis. Thus, fistulas outperformed grafts in white men and younger men, but were not clearly better in black men and older men. A recent European study observed a lower cumulative survival of fistulas as compared with grafts among patients aged 70 or older46. Top of page STRATEGIES TO INCREASE FISTULA PREVALENCE AMONG DIALYSIS PATIENTS Taken together, the body of published literature suggests that the success rate of fistulas is not uniform among patient subgroups. When one considers all factors required for the long-term success of fistulas, including placement, successful maturation, and need for subsequent salvage procedures, the likelihood of success varies substantially among groups Table 5. Specifically, the success rate of fistulas is less likely among women, blacks, and older patients. This suggests that even with optimal efforts to maximize the use of fistulas, the success rate among dialysis units may vary depending on patient characteristics. It is important to keep such differences in mind when comparing vascular access prevalence among dialysis units. For example, it is likely that units that dialyze men exclusively (such as Veterans Hospital-affiliated units) will have a higher than average proportion of patients with fistulas. In contrast, units with large black populations are likely to have a lower than average prevalence of fistulas. Notwithstanding these caveats, concerted and focused efforts should increase the prevalence of patients dialyzing with fistulas at any unit, regardless of the specific patient case-mix. Table 5 - Overall success rate in achieving adequate (useable) fistulas when preoperative vascular mapping is used. Table 5 - Overall success rate in achieving adequate (useable) fistulas when preoperative vascular mapping is used - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the authorFull table A multidisciplinary approach to vascular access Multiple individuals are involved in the management of vascular access, including nephrologists, access surgeons, radiologists, dialysis nurses, and the patient. Achieving optimal vascular access outcomes requires agreement on a common set of goals by all these individuals, close collaboration, and good communication10. A key feature of a successful multidisciplinary approach to vascular access is having a dedicated access coordinator who acts as a liaison between all the services involved, schedules all access procedures, and maintains a computerized database. Prospective tracking of vascular access procedures and their complications is critical to evaluate whether changes in practice patterns result in improved outcomes. The multidisciplinary approach also can increase fistula placement in pre-dialysis patients by streamlining the referral process. Rationale for preoperative vascular mapping At most clinical centers, the surgeon decides what type of vascular access to place and at which anatomic location on the basis of physical examination alone, with and without a tourniquet. This type of approach may result in the use of inappropriate vessels for fistula construction, or conversely, failure to recognize a vessel suitable for fistula construction. Some patients may appear to have an excellent vein with a suitable caliber on inspection. However, sonographic evaluation may reveal an unsuspected stenosis or thrombosis in a more proximal portion of that vein, which would render that particular vein unsuitable for construction of a fistula. In other patients, physical examination may reveal no suitable veins for construction of a fistula. Sonographic evaluation, however, may reveal suitable veins that were simply too deep to appreciate clinically. Use of such veins may require venous transposition procedures to ensure that the fistula is superficial enough to be cannulated successfully for dialysis. The caliber of the vessels used for fistula construction is an important factor predicting the likelihood of its maturation. For example, Malovrh reported that the patency rate of fistulas for dialysis at three months was just 36% if the preoperative internal diameter of the artery was <1.5 mm, but was 83% when this diameter was>1.5 mm47. Moreover, the flow rates in the fistula were higher in the second group, as compared with the first group. Similarly, Wong et al noted that if the artery or vein diameter was <1.5 mm, the fistula always failed to mature48. However, when the diameters were higher, it was not possible to predict on the basis of vessel diameter whether a given fistula would successfully mature. Similarly, we found that as long as the artery and vein met minimum diameter criteria (2 mm for the artery and 2.5 mm for the vein), there was no correlation between vessel diameter and likelihood of fistula maturation13. The mean artery and vein diameters during preoperative mapping are not significantly different between diabetic and non-diabetic patients. However, vascular calcifications are more frequent among diabetics than non-diabetics (64 vs. 35%)43. In one study preoperative vascular mapping limited the number of vessels and extremities available for vascular access placement in 66% (33 of 50) patients. Three-quarters of those patients had not had a previous vascular access. The most common abnormality observed was insufficient vein diameter49. We recently performed a pilot study to evaluate the impact of routine preoperative sonographic vascular mapping on the surgeon's choice of access50. Seventy consecutive patients scheduled for construction of a permanent vascular access were enrolled. The criteria for placement of a fistula were defined prospectively, and included a minimum artery diameter of 2 mm, a minimum vein diameter of 2.5 mm, and lack of stenosis or thrombosis in the draining vein or central veins51. The surgeon initially determined what type of vascular access to place and at which location, on the basis of a physical examination alone. Subsequently, the surgeon reviewed the results of the preoperative vascular mapping, and was asked whether those would change his intended surgical procedure. Preoperative ultrasound mapping resulted in a change in the planned surgical procedure in 31% of the patients. In most cases, the surgeon decided to place a fistula, rather than the planned graft, or to place the intended fistula at a different anatomic location50. Description of preoperative vascular mapping procedure Vascular measurements are performed with the patient in a seated position, with their arm resting comfortably on a Mayo stand50. All measurements are in the anteroposterior dimension in the transverse plane. The minimum vein diameter for a native arteriovenous fistula is 0.25 cm. The minimum vein diameter for graft placement is 0.40 cm. The minimum arterial diameter for either fistula or graft placement is 0.20 cm. Veins are assessed for stenosis, thrombus and sclerosis (thickened walls). First, the radial artery diameter at the wrist is measured. A tourniquet is then placed at the mid to upper forearm. The veins about the wrist are percussed for two minutes, with special emphasis on the cephalic vein area. Sequential measurements are made of the cephalic vein at the wrist, mid and cranial forearm. Any other dorsal or volar veins at the wrist also are measured and followed up the arm, according to established diameter criteria. The tourniquet is sequentially moved up the arm, and cephalic, basilic, and brachial vein diameters are measured. After the tourniquet is removed, the subclavian and jugular veins are assessed for stenosis and thrombus. Evidence of a more central stenosis is determined by analysis of the spectral Doppler waveform for respiratory phasicity and transmitted cardiac pulsatility. Measurements are recorded on a worksheet. The sonographic measurements are used by the surgeon to select the most appropriate vascular access, on the basis of the following list agreed upon by our nephrologists, radiologists and vascular surgeons, from most desirable to least desirable: Non-dominant forearm cephalic vein fistula Dominant forearm cephalic vein fistula Non-dominant, or dominant upper arm cephalic vein fistula Non-dominant or dominant upper arm basilic vein transposition fistula Forearm loop graft Upper arm straight graft Upper arm loop graft (axillary artery to axillary vein) Effect of preoperative vascular mapping on vascular access outcomes Four clinical studies have evaluated prospectively the effect of instituting preoperative vascular mapping on vascular access outcomes13,35,51,52. In each case, using preoperative physical examination alone, only a small proportion of patients (0 to 34%) received a fistula, rather than a graft Table 6. Following introduction of routine preoperative vascular mapping, the proportion of patients receiving fistulas increased to 63 to 100%Table 6. Finally, a retrospective study reported that a combination of preoperative venography and intra-operative angioscopy resulted in fistula placement in 76% of patients34. The effect of such a program on the primary failure rate of fistulas constructed was inconsistent among studies. Whereas one study demonstrated a substantial decrease in the primary failure rate of fistulas51, two other reports observed only slight increases or decreases in the primary failure rate Table 613,35. The net effect of preoperative vascular mapping was a consistent increase in the prevalence of patients successfully dialyzing with fistulas. In three studies only 5 to 16% of the patients were dialyzing with fistulas before implementation of routine preoperative vascular mapping; this proportion increased substantially (34 to 68% of patients) after introduction of such a program Table 6. An additional study, which did not provide a historical control, reported that preoperative vascular mapping resulted in 62% of patients receiving a fistula, and a 25% primary failure rate43. Finally, a recent study from Turkey observed a reduction of the non-maturation rate of fistulas from 25 to 6% after implementing preoperative vascular mapping53. Table 6 - Effect of preoperative vascular mapping on vascular access outcomes. Table 6 - Effect of preoperative vascular mapping on vascular access outcomes - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the authorFull table When preoperative vascular mapping is used to guide the surgeon, the inferior outcomes of forearm fistulas relative to upper arm fistulas were no longer observed. Prior to the use of preoperative mapping, the maturation rate at our center was 34% for forearm fistulas and 59% for upper arm fistulas25. With preoperative mapping, the respective maturation rates were 59 and 56%, respectively13. The improvement of forearm fistula adequacy was particularly striking among women (from 7 to 36%) and diabetic patients (from 21 to 50%). However, using these objective criteria, fistula placement was about one-third less likely in women than men, and about one-third less likely in black than white patients13. Thus, a fistula was possible in 92% of white males, but only 43% of black females. Similarly, Stehman-Breen et al reported that the first permanent vascular access placed was less likely to be a fistula in women, blacks, older patients, diabetics, and obese patients24. About 46% of fistulas placed with the benefit of preoperative vascular mapping at our center were in the upper arm, rather than the forearm. Fistula construction was more likely to be in the upper arm in women than men (64 vs. 36%), and more likely in blacks than whites (54 vs. 34%)13. Taken together, these observations suggest that women and black patients have smaller vessels. Preoperative vascular information also can be obtained by venography. However, this approach suffers from several disadvantages. First, it evaluates just the veins, not the arteries. Second, there is a risk of inducing phlebitis, thereby jeopardizing the vein intended for fistula construction. Finally, among patients not yet on dialysis, exposure to radiocontrast dye may worsen the renal failure and precipitate an earlier requirement for dialysis. Digital subtraction venography with gadoterate meglumine may provide comparable information to standard venography without incurring the risk of nephrotoxicity, but is considerably more expensive than the use of nonionic iodinated contrast agents54. Despite its shortcomings, venography is more sensitive than ultrasound for detection of stenosis or thrombosis in the central veins, and may have a role in selected patients in whom there is a clinical suspicion for this problem. Sonography has, however, emerged as the method of choice for the preoperative assessment of the arteries and veins to assist the surgeon in planning vascular access placement. Assessment of fistula maturation In spite of the use of preoperative sonographic data to select vessels suitable for fistula construction, some fistulas still fail to mature adequately for dialysis use. There may be additional measurements obtained by preoperative Doppler ultrasound that predict clinically successful fistulas. These type of evaluations have not been addressed systematically, but may include a change in Doppler flow signal after fist clenching47 or a preoperative subclavian venous flow rate>400 mL/min55.

The expertise of dialysis nurses plays an important role in the assessment and successful cannulation of new fistulas. It is more technically challenging to cannulate fistulas as compared with grafts. Experienced dialysis nurses can successfully predict fistula maturation 80% of the time37. New dialysis nurses require considerable practice and supervision before they become adept at assessing and cannulating new fistulas. Given the much lower prevalence of fistulas among U.S. than European dialysis patients, U.S. dialysis nurses also have fewer opportunities to practice. Infiltration of new fistulas appears to occur more commonly with fistulas than grafts; when this occurs, there is a further delay in the successful use of a fistula for dialysis. Clearly, concerted efforts to enhance the proficiency of nurses in using fistulas for dialysis is a critical element in increasing the prevalence of patients dialyzing successfully with fistulas. During the present transition phase, when the prevalence of fistulas is increasing, it is extremely disappointing when a potentially functional fistula is compromised by laceration, infiltration, and serious hematoma at the time of its initial use. Perhaps formal certification of nurses for initial cannulation of fistulas should be considered. In no instance should the initial cannulation be delegated to a relatively inexperienced patient care technician.

Fistula maturation is usually evaluated by subjective physical examination by the dialysis nurse or nephrologist. We recently correlated objective postoperative sonographic measurements with clinical outcomes (adequacy for dialysis) of fistulas constructed after preoperative vascular mapping37. When the ultrasound revealed a minimum vein diameter>0.4 cm or a blood flow rate>500 mL/min, about 70% of the fistulas matured. If both criteria were met, the likelihood of fistula maturation was 95%; however, if neither criterion was achieved, the likelihood of fistula adequacy for dialysis was only 33%. Female patients were less likely than males to achieve the minimum vein diameter (40 vs. 69%). These observations suggest that veins in women may be less likely to dilate, thereby contributing to a 30% lower maturation rate, even when preoperative vascular mapping is used13.

It would be helpful to identify the earliest time point at which subsequent maturation of a new fistula could be evaluated. This would result in either prompt intervention to salvage an immature fistula or in timely placement of a new vascular access, if the existing fistula is not likely to mature. An increase in blood flow occurs very early after fistula construction. In one prospective study, the mean arterial inflow on preoperative evaluation was 30 mL/min. Within 24 hours of surgery, the fistula blood flow was up to 472 mL/min, and by one week it had increased further to 861 mL/min55. A second prospective study observed a mean preoperative arterial inflow of 47 mL/min, which increased to 184 mL/min at one day, 202 mL/min at one week, 488 mL/min at eight weeks, and 562 mL/min at 12 weeks47. Retrospective analysis from our institution found that the blood flow was not significantly different in the second, third, or fourth month following fistula construction (707, 685, and 807 mL/min, respectively)37. Similarly, the minimum vein diameter was similar in the second, third, and fourth months after fistula placement (0.45, 0.46, and 0.39 cm, respectively)37.

An early increase in access blood flow and vein diameter suggests that many fistulas could be cannulated successfully within a few weeks of their construction. However, in the United States the typical time interval from fistula placement to its successful use for dialysis is two to four months12,13,26,56. New A-V fistulas are cannulated much earlier in Europe, as compared to the United States. Cannulation of fistulas within one month of their construction occurs 52% of the time in Europe, but only 2% of the time in the United States. Moreover, there is no association between the time of first cannulation and risk of fistula failure (abstract; Young et al, J Am Soc Nephrol 11:201A, 2000). The explanation for these striking practice differences among countries is not apparent. The shorter time to fistula cannulation in Europe may contribute to the higher use of fistulas in Europe at initiation of dialysis, but would not account for the higher fistula use among prevalent dialysis patients.
Salvage of immature fistulas

Some fistulas fail to mature due to unrecognized stenosis in the draining vein, or large tributary veins that limit the blood flow through the main draining vein. An aggressive approach to evaluating immature fistulas for evidence of correctable abnormalities, with appropriate interventions, can improve the maturation rate. Beathard, Settle and Shields reported on their experience with 71 patients referred because of inadequate maturation of their fistulas36. Eight were not evaluated further because they were believed to have an inadequate arterial inflow. The remaining 63 patients underwent angioplasty of a stenotic lesion in the draining vein, ligation of one or more tributary veins, or a combination of both procedures. As a result of these salvage attempts 82.5% of the fistulas matured adequately to be used for dialysis.

In some cases surgical procedures may be helpful in salvaging a fistula. For example, in some obese patients, a postoperative ultrasound may reveal a well-developed fistula with an adequate diameter and blood flow that is simply too deep to be cannulated. A second surgical procedure to superficialize the fistula, by tunneling it subcutaneously, can render the fistula accessible to the dialysis nurse13.
Salvage of clotted and stenosed A-V fistulas

Mature A-V fistulas are much less likely to clot than are grafts Table 3. Unfortunately, when they do clot, thrombectomy is much more time-consuming and technically challenging for fistulas than grafts. Whereas declotting A-V grafts is a fairly standardized procedure, declotting a fistula requires considerable ingenuity and improvisation. Due to the low success rate of thrombectomy of fistulas, most U.S. centers have abandoned efforts at this procedure, and simply proceed with placement of a new vascular access once a fistula has clotted11,12,13. Some of the difficulties encountered in declotting fistulas include the thin venous wall, difficulty in localizing the anastomosis, the multiple possible locations of stenosis, the frequency of encountering very tight stenoses, the high frequency of venous aneurysms, and the large volume of clot57. Two groups of European investigators have recently reported good success rates in declotting A-V fistulas, using creative and meticulous radiologic techniques57,58. The immediate technical success rate was about 90%, and the primary patency rate at six months was about 50% in both studies. The patency rate was much worse for upper arm fistulas than for forearm fistulas57. As the use of fistulas increases in the United States, it will be imperative that interventional radiologists and nephrologists become familiar and proficient with the methodology of fistula thrombectomy.

Although the frequency is lower than with grafts, fistulas also are prone to developing stenotic lesions11. Analogous to grafts, monitoring for hemodynamically significant stenosis and elective angioplasty can reduce the frequency of fistula thrombosis. A program of vascular access blood flow monitoring reduced the thrombosis rate of fistulas from 0.14 to 0.07 events per access-year at one center11. The primary patency following angioplasty is similar for fistulas and grafts11,59. McCarley et al observed a median intervention-free survival after angioplasty of 161 days for fistulas and 148 days for grafts11. Similarly, Turmel-Rodrigues reported primary patency at six months after angioplasty to be 67% in fistulas, as compared with 53% in grafts59.
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DIFFERENCES BETWEEN VASCULAR ACCESS IN THE U.S. AND EUROPE

The ongoing Dialysis Outcomes and Practice Patterns Study (DOPPS)17 has highlighted several significant differences in vascular access management in Europe, as compared with the United States. We have touched on some of these findings in various parts of this review. It will be important to explore these differences in the future, so as to increase the prevalence of fistula use in the U.S.

The use of fistulas is much more common in Europe than the United States, whether one looks at incident or prevalent patients18. Having more patients with fistulas gives European dialysis nurses more experience with cannulation of fistulas and the interventionalists more experience with fistula salvage and interventions.

Hemodialysis patients in Europe have lower co-morbidity than do patients in the United States Table 118. This difference may contribute, in part, to the higher prevalence of fistulas among European dialysis patients, but is unlikely to account by itself for the fourfold difference.

Fistulas in Europe are cannulated much earlier in Europe than in the United States (abstract; Young et al, J Am Soc Nephrol 11:201A, 2000). The reasons for this difference are not evident, but the presence of a large cadre of experienced dialysis nurses for initial cannulation may be a factor.

Mean dialysis blood flows are substantially lower in Europe than in the United States (mean flow, 300 vs. 412 mL/min; abstract; Dykstra et al, J Am Soc Nephrol 11:182A, 2000). Accepting lower dialysis blood flows may cause some fistulas to be considered useable in Europe, whereas they would be deemed inadequate in the United States.

European hemodialysis units have substantially higher staffing by registered nurses. Specifically, the ratio of registered nurse to patient dialysis-hour was 38% higher in Europe than in the United States (abstract; Mapes et al, J Am Soc Nephrol 12:337A, 2001). More experienced nurses are likely to have a higher success rate in cannulating fistulas.

Remarkably, hospitalization rates for vascular access problems are equally common in Europe and in the United States. Vascular access accounted for 25% of all hemodialysis patient hospitalizations in the United States and 24% of all hospitalizations in Europe (abstract: Young et al, J Am Soc Nephrol 10:259A, 1999). One would expect a lower rate of vascular access hospitalization in Europe, given the high prevalence of fistulas. However, a meaningful comparison is difficult due to the lack of information as to which procedures were for primary access placement, and which were done to salvage a failing or failed vascular access.

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SUMMARY

Are the DOQI guidelines regarding fistulas achievable in the United States? The maximal achievable fistula prevalence is likely to vary among units, as a result of differences in gender, race, and co-morbidity mix. Nonetheless, adoption of specific measures outlined in this review, including a multidisciplinary approach to vascular access, early referral for vascular access, restriction of access procedures to surgeons with demonstrable interest and experience, routine preoperative vascular mapping, increased utilization of upper arm fistulas, enhanced training and certification of dialysis staff in fistula cannulation techniques, and efforts to salvage immature and thrombosed fistulas, will undoubtedly increase fistula prevalence in any hemodialysis unit.
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References

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60. Levinsky NG. The organization of medical care: Lessons from the Medicare End-Stage Renal Disease Program. N Engl J Med 1993; 329: 1395−1399 10.1056/NEJM199311043291907. | Article | PubMed | ISI | ChemPort |
61. Rostand SG, Gretes JC & Kirk KA et al. Ischemic heart disease in patients with uremia undergoing maintenance hemodialysis. Kidney Int 1979; 16: 600−611. | PubMed | ISI | ChemPort |
62. Kinnaert P, Vereerstraeten P, Toussaint C & Van Geertruyden J. Nine years' experience with internal arteriovenous fistulas for haemodialysis: A study of some factors influencing the results. Br J Surg 1977; 64: 242−246. | PubMed | ISI | ChemPort |
63. Bonalumi U, Civalleri D & Rovida S et al. Nine years' experience with end-to-end arteriovenous fistula at the "anatomic snuffbox" for maintenance hemodialysis. Br J Surg 1982; 69: 486−488. | PubMed | ISI | ChemPort |
64. Reilly DT, Wood RFM & Bell PRF. Prospective study of dialysis fistulas: Problem patients and their treatment. Br J Surg 1982; 69: 549−553. | PubMed | ISI | ChemPort |
65. Palder SB, Kirkman RL & Whittemore AD et al. Vascular access for hemodialysis: Patency rates and results of revisions. Ann Surg 1985; 202: 235−239. | PubMed | ISI | ChemPort |
66. Winsett OE & Wolma FJ. Complications of vascular access for hemodialysis. South Med J 1985; 78: 513−517. | PubMed | ISI | ChemPort |
67. Churchill DN, Taylor DW & Cook RJ et al. Canadian hemodialysis morbidity study. Am J Kidney Dis 1992; 19: 214−234. | PubMed | ISI | ChemPort |
68. Hodges TC, Fillinger MF & Zwolak RM et al. Longitudinal comparison of dialysis access methods: Risk factors for failure. J Vasc Surg 1997; 26: 1009−1019. | PubMed | ISI | ChemPort |
69. Golledge J, Smith CJ & Emery J et al. Outcome of primary radiocephalic fistula for haemodialysis. Br J Surg 1999; 86: 211−216 10.1046/j.1365-2168.1999.01007.x. | Article | PubMed | ISI | ChemPort |
70. Konner K. Primary vascular access in diabetic patients: an audit. Nephrol Dial Transplant 2000; 15: 1317−1325 10.1093/ndt/15.9.1317. | PubMed | ISI | ChemPort |
71. Murphy GJ, White SA & Nicholson ML. Vascular access for haemodialysis. Br J Surg 2000; 87: 1300−1315 10.1046/j.1365-2168.2000.01579.x. | Article | PubMed | ISI | ChemPort |
72. Revanur VK, Jardine AG, Hamilton DH & Jindal RM. Outcome for arterio-venous fistula at the elbow for haemodialysis. Clin Transplant 2000; 14: 318−322 10.1034/j.1399-0012.2000.140407.x. | Article | PubMed | ISI | ChemPort |
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Acknowledgments

This manuscript was supported in part by Dr. Allon's NIDDK grant (1 K24 DK59818-01).

Problems with Fistula's, and Learning Curves 101

2012-01-25T19:10:00.000-06:00

Possible problems with hemodialysis

Hemodialysis is a much more intensive treatment than peritoneal dialysis: all the dialysis is condensed into a few sessions a week. Many potential problems with hemodialysis are due to this fact.

Rapid changes in blood pressure
The speed at which water is removed from the blood during hemodialysis may cause a sharp drop in blood pressure. This makes some patients feel unwell, either during or after the treatment session. Fainting, vomiting, cramps, temporary loss of vision, chest pain, irritability, and fatigue can occur.

Fluid overload
Hemodialysis patients sometimes develop a condition called fluid overload between dialysis sessions. Excess water collects under the skin at the ankles and elsewhere in the body, including the lungs.

To avoid fluid overload, hemodialysis patients should restrict the amount of fluid they drink. This also helps avoid the problems caused by rapid physical changes during hemodialysis.

Restrictions on fluid intake for hemodialysis patients are stricter than those for peritoneal dialysis patients.

Hyperkalemia
Hyperkalemia is caused by too much potassium in the blood and can interfere with the heart's rhythm. Severe hyperkalamia can cause the heart to stop.

Most hemodialysis patients are asked to restrict their intake of foods that contain a lot of potassium.

Loss of independence
Although patients on hemodialysis have "days off", some feel that having to travel to the Dialysis center or self-care unit several times a week, every week of the year, is a burden.

Home hemodialysis and peritoneal dialysis patients do not have this burden since they are treated at home.

Blood-borne viruses
Some patients have concerns about contracting blood-borne viruses, such as hepatitis B or C, or HIV. All Dialysis centers take measures to protect patients from this risk. If you are concerned, you should discuss your concerns with the medical team.

Amyloidosis
Renal bone disease is not the only cause of bone pain in patients with kidney failure. Bone pain can also be caused by a condition called dialysis amyloidosis.

This condition can develop 10 years or so after the start of dialysis. It is caused by the build up of a protein called amyloid, which is not easily removed by dialysis. It is deposited in joints all over the body, leading to joint and bone pain. At present there is no effective treatment for this condition. It can be halted, to an extent, by transplantation.

Other potential problems with hemodialysis, described below, are related to access.

Fistulas
Not all fistulas work perfectly. Some never develop into a vein that is large enough. Some work well for years and then suddenly stop. In either case, a new fistula (or sometimes a graft) will have to be made in another part of the body. Only a limited number of veins can be made into a fistula. Caring for the fistula is important.

Access can be a particular problem for patients with diabetes or for children since the blood vessels are often very narrow.

HD catheters
HD catheters may stop working because they become blocked by a blood clot. If this happens, they will have to be declotted or replaced. Only a limited number of veins are suitable for catheter insertion.

Needles
If access is achieved via a fistula or graft, it is necessary to insert needles at the start of each dialysis session. Even with a local anesthetic, some patients find this painful.

Bleeding
Some patients may have problems with bleeding from the fistula either during or after dialysis. There are now special bandages available which can help stop the bleeding more quickly. Most Dialysis centers can supply these or advise where they can be obtained.

Infections
There is a risk of picking up an infection during a dialysis session. Infections can usually be treated with antibiotics. Strict attention to hygiene during the preparation of the dialysis machine and access can help prevent infection.

Exit site infections may occur where a dialysis catheter comes out of the skin. The area around the exit site becomes red and inflamed. The infection can "tunnel" inside the body, following the route of the catheter. Most exit site infections respond well to antibiotics.

Some people feel anxious before starting dialysis.

"I am very nervous, but eventually decided to go ahead with it. I am particularly fearful of whether it will be visible. Also, I don't like needles. At the moment I don't mind coming here (to the Dialysis center), but wonder if I will dread it when they start using the fistula." - Anon

Most people get used to it after a while.

"It had to be done. I'm not bothered about how it (the fistula) looks; only occasionally I notice it in the mirror. It's a way of life - it's my lifeline" - Ron Broad

Dialysis Fistula's

2012-01-25T19:08:00.000-06:00

Overview
Introduction

Hemodialysis fistulas are surgically created communications between the native artery and vein in an extremity. Direct communications are called native arteriovenous fistulas (AVFs). Polytetrafluoroethylene (PTFE) and other materials (Dacron, polyurethane, bovine vessels, saphenous veins) are used or have been used as a communication medium between the artery and the vein and are termed prosthetic hemodialysis access arteriovenous grafts (AVGs). The access that is created is routinely used for hemodialysis 2-5 times per week.[1]

Many patients who are not candidates for renal transplantation or those for whom a compatible donor cannot be secured are dependent on hemodialysis for their lifetime. This situation results in the long-term need for and use of dialysis access. The preservation of patent, well-functioning dialysis fistulas is one of the most difficult clinical problems in the long-term treatment of patients undergoing dialysis. As many as 25% of hospital admissions in the dialysis population have been attributed to vascular access problems, including fistula malfunction and thrombosis.
History of the management of dialysis access

Historically, native fistula or graft malfunction and thrombosis were treated by using surgical thrombectomy and revision, resulting in the eventual exhaustion of the veins and the need to create a new access. Initially applied in the 1980s, percutaneous techniques such as balloon angioplasty (percutaneous transluminal angioplasty [PTA]), thrombolysis, and mechanical thrombectomy allowed the treatment of stenosis and fistula thrombosis without surgery.

In the past 2 decades, interventional radiologists have increasingly been involved in angiographic evaluation and treatment of malfunctioning and occluded hemodialysis access. The multidisciplinary management of dialysis access coordinated among interventional radiologists, vascular surgeons, and nephrologists has proven extremely effective in prolonging the patency of the vascular access and decreasing the morbidity and mortality of patients with chronic renal failure.[2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13]

Examples of a vessel with long-segment stenosis before and after treatment are provided below.
Long-segment outflow vein stenosis before percutanLong-segment outflow vein stenosis before percutaneous transluminal angioplasty. Image obtained after percutaneous transluminal angImage obtained after percutaneous transluminal angioplasty in a long-segment stenosis (same patient as in Image above).
Indications

Less than 15% of dialysis fistulas remain patent and can function without problems during the entire period of a patient's dependence on hemodialysis. The mean problem-free patency period after creation of native fistulas is approximately 3 years, whereas prosthetic polytetrafluoroethylene (PTFE) grafts last 1-2 years before indications of failure or thrombosis are noted. After multiple interventions to treat underlying stenosis and thrombosis, the long-term secondary patency rates for native fistulas are reportedly 7 years for fistulas in the forearm and 3-5 years for fistulas in the upper arm; prosthetic grafts remain patent for up to 2 years.
Causes of dialysis fistula failures

To the authors' knowledge, all observations and publications reported to date indicate that for prosthetic grafts, fistula failure and eventual occlusion occur most commonly as a result of the progressive narrowing of the venous anastomosis; for native fistulas, failure occurs most commonly as a result of the narrowing of the outflow vein. In some reports, venous anastomosis is identified in more than 90% of grafts. The primary underlying pathophysiologic mechanism responsible for causing the failure is intimal hyperplasia at the anastomotic site. Additional causes include surgical and iatrogenic trauma, such as repeated venipunctures. Stenoses along the venous outflow and in intragraft locations (for prosthetic PTFE grafts) are also common and require appropriate treatment.
When to consult with an interventional radiologist

The following are indications for consultation with an interventional radiologist:

Abnormal findings on clinical examination, such as weak thrill or pulsatility
Direct palpation of stenosis
Insufficient inflow, such as stenosis in the supplying native artery or proximally in the subclavian or brachiocephalic artery
Vacuum phenomenon
Identification of high venous pressures in accordance with the protocol appropriate for the specific type of hemodialysis machine
Suboptimal blood flow (according to the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative 1997 guidelines: 700-800 mL/min for prosthetic grafts and 500 mL/min for native fistulas) or recirculation while the patient receives hemodialysis[14]
Demonstration of stenoses in a previous Doppler ultrasonographic examination
Ipsilateral arm edema and/or collateral venous pathways suggestive of a central venous stenosis

Contraindications

The presence of an infection is the only absolute contraindication to angiography and percutaneous treatment of a dysfunctional or thrombosed dialysis access.

Preparation
Angiography

Angiographic examination of the entire arteriovenous access from the inflow native artery to the right atrium is undertaken to evaluate a failing hemodialysis access. It is important that all underlying lesions be identified and treated. Even in cases in which a stenosis has been identified on ultrasonograms, additional lesions should be searched for and treated to prevent occlusion and recurrence of access malfunction.

Angiography is performed under sterile conditions after (1) a direct puncture is made in the arterial limb of the graft with the needle pointing toward the venous outflow or (2) a puncture is made in the native vein of the arteriovenous fistula (AVF) just distally to the anastomosis.

This imaging study may be performed by using the outer plastic sheath of a 19-gauge angiocatheter or by using a 4-French (4-F) sheath of a micropuncture set. Arterial anastomosis must always be evaluated, and it is achieved by injecting contrast material via the same access site as described above during a temporary occlusion of the outflow with the use of manual compression or a pressure cuff to allow reflux of contrast agent via the anastomosis into the native artery.

In addition to venous lesions, the arteriovenous anastomosis and the nearby portion of the native artery also should be evaluated. In patients with native AVFs, a direct arterial puncture may be performed to evaluate inflow problems. In certain instances, evaluation to the level of the subclavian and innominate arteries is performed to identify the underlying stenosis.

Technique
Percutaneous Transluminal Angioplasty

Percutaneous transluminal angioplasty (PTA) should be performed to treat hemodynamically significant anastomotic and outflow venous lesions and purely arterial inflow stenoses after the fistula is accessed toward the venous and arterial limbs or, in native fistulas, the arteriovenous anastomosis. A hemodynamically significant lesion is usually identified on angiography, because a stenosis causing a decrease in luminal diameter of more than 30% may be accompanied by the formation of collateral blood vessels (see the image below).
Long-segment outflow vein stenosis before percutanLong-segment outflow vein stenosis before percutaneous transluminal angioplasty.

Once identified, most venous lesions can be treated with the use of PTA (see the following image). Results from centers that implemented aggressive surveillance programs and PTA treatment in identified stenoses demonstrated a significant decrease in access graft thrombosis and replacement rates. Patency rates can be prolonged by repeating PTA procedures as required without sacrificing the outflow vein.
Image obtained after percutaneous transluminal angImage obtained after percutaneous transluminal angioplasty in a long-segment stenosis (same patient as in Image above).
PTA versus surgical intervention

Direct comparisons between PTA and surgical revisions are not easy and are rarely undertaken. The percutaneous approach allows detailed angiographic evaluation of the entire fistula to the right atrium, as well as PTA of identified lesions, during the same session. PTA and stent deployment can be performed in most patients via the initial angiography puncture site of the access and after appropriate dilatation and vascular sheath placement, without surgical incision (see Stent Deployment). A second retrograde puncture (ie, a puncture toward the arteriovenous anastomosis) may be needed to treat stenoses close to the anastomosis of native fistulas.

Treatment may be performed in an outpatient setting; the access may be used for hemodialysis immediately after the procedure.
Stent Deployment

Although a variety of stents are available, self-expanding stents are generally preferred for the treatment of dialysis access stenosis because of their flexibility and radial force. Most interventional radiologists agree that a stent is indicated to treat PTA-related flow-limiting ruptures or dissections that persist after prolonged local balloon inflation. Relative indications, such as recoil of a previously successfully treated stenosis by PTA, should be treated after a discussion with the vascular surgeon and after the surgical options and possible future access sites are evaluated.

Stent placement is contraindicated in patients with PTA-resistant stenoses.[15, 16]
Central vein occlusion

The discrepancy between the reported results after stent deployment in the central veins and the observed stenosis recurrence in the stent or at its edges makes the systematic use of stents in the central vein questionable. The patency of a given vascular access is thus prolonged significantly, although most published reports indicate that this is the result of multiple procedures that are required after stent deployment to maintain good fistula function.
Catheter-Directed Thrombolysis

Thrombosis of dialysis access is an unfortunate but common event in patients with grafts who undergo long-term dialysis; in native fistulas, this complication occurs more rarely. Thrombosis is the result of progressive narrowing in one of multiple sites in the arteriovenous shunt and its pathway to the right atrium.

Historically, temporary hemodialysis catheter placement and/or surgical thrombectomy with hospital admission were the only available treatments. Typically, with surgical treatment, a portion of the outflow vein is sacrificed. Repeated surgical revisions soon exhaust the available sites for peripheral access, exasperating patients and physicians alike. In more recent years, a growing number of institutions provide percutaneous treatment on an outpatient basis, generally within 24 hours of the event.

The consequences of thrombosis of hemodialysis access with regard to patients' quality of life, public health concerns, and society in general are well known. The advantages of percutaneous radiologic interventions for the surveillance and treatment of the failing access also apply to clotted grafts and fistulas.

Angiography is performed to evaluate the condition of the outflow to the right atrium (and, for native fistulas, inflow) before any attempt is made to recanalize an occluded access. The entire recanalization procedure is completed within hours, after which the patient can be discharged and the access used immediately for dialysis. Perhaps the most valuable benefit of percutaneous declotting is the preservation of the entire outflow vein. Repeated procedures can be performed to preserve access patency.
Pulsed-spray thrombolysis

Many percutaneous techniques with comparable results have been described in the treatment of hemodialysis access occlusion. One of the first and most commonly performed techniques is pulsed-spray thrombolysis (PST) with urokinase (UK) and PTA. The technique underwent several modifications, which mostly shortened the initial procedure time to less than 2 hours and decreased the overall amount of thrombolytic agent needed. However, since the disappearance of UK from the US market in 1999, different forms of tissue plasminogen activator (t-PA) have been used in PST, with similar results.[17, 18, 19, 20, 21, 22, 23, 24, 25]

Additional recanalization techniques include balloon thrombectomy and thromboaspiration, PST with sodium chloride solution and heparin, and the use of a series of mechanical thrombectomy devices.[26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43]
Procedure

The graft is accessed in a crisscross manner.

Using a micropuncture 21-gauge needle, the graft in the arterial limb is initially entered, pointing toward the venous outflow. Over a 0.018-inch (in) Cope Mandril wire, the needle is exchanged for the introducer sheath of a micropuncture set. Initially, venous outflow is evaluated to confirm patency. If outflow is occluded, an attempt is made to pass a wire and, subsequently, a catheter to evaluate outflow. When adequate outflow is documented, PST or mechanical thrombectomy is initiated.

Thrombolysis can be performed before evaluating the outflow. One method for evaluating outflow is the lyse-and-wait technique, in which the thrombolytic agent is administered while the patient waits for the angiography suite to become available.[44] At least in theory, outflow patency reduces the risk of arterial emboli during the thrombolysis or thrombectomy procedure, which is performed within the graft, because outflow patency allows the thrombus to enter the venous outflow rather than move via reflux into the native artery.

Using a micropuncture set as described above, a second puncture is then made in the venous limb of the graft, pointing toward the arterial anastomosis. A 0.035-in wire is advanced in the arterial limb. Care is taken to avoid forcing the wires and catheters via the arterial anastomosis into the native artery, so as to prevent inadvertent arterial embolization.

A 5-French (5-F) multiside-slit pulse-spray infusion catheter of appropriate length for the graft (5-20 cm available) is placed over the 0.035-in wires in a crisscross manner. The tip of the venous catheter is advanced just past the venous anastomosis in the outflow vein. The second infusion catheter is placed over the 0.035-in wire in the arterial limb, with the tip positioned near but not across the arterial anastomosis. In cases involving straight and short grafts, thrombolysis via only the venous catheter is effective.

When thrombolysis or thrombectomy has been completed in both limbs of the graft, contrast-enhanced venography of the entire venous outflow to the right atrium is performed. At this point, all sites of stenosis can be identified in a pattern of distribution similar to that for stenoses associated with patent failing grafts. In more than 85% of reported cases, a venous anastomotic lesion requiring PTA is present. As a rule, such lesions are the result of intimal hyperplasia; therefore, these lesions are particularly firm and resistant. A high-pressure balloon is used routinely, with good results.

At the end of thrombolysis and mechanical thrombectomy and after the confirmation of venous outflow patency, the arterial anastomosis is addressed. Typically, a residual arterial plug is present and must be dislodged. This plug is resistant to thrombolysis, because it consists of impacted erythrocytes and fibrin (white clot). Dislodgement is usually achieved by performing a Fogarty-type balloon embolectomy, during which the balloon is advanced into the native artery via the arterial-limb directed access in the graft. Subsequently, the balloon is retracted from the graft in a retrograde manner. Some use thromboaspiration or a percutaneous thrombectomy device (PTD) to treat the arterial plug. See the following images.
Dislodgement of arterial plug with the use of a FoDislodgement of arterial plug with the use of a Fogarty balloon. Patent loop of arteriovenous graft after successfuPatent loop of arteriovenous graft after successful thrombolysis, which included percutaneous transluminal angioplasty of venous anastomosis and dislodgement of arterial plug.

At this point, inflow to the graft is established; a palpable thrill is usually present over the graft as a result of fast blood flow. The recanalization procedure is usually complete at this point. The procedure requires 60-120 minutes to perform.

If no thrill is present, inflow is reevaluated, and the Fogarty balloon embolectomy or another maneuver is repeated as needed. Rarely, a lesion is present in the native artery or in the arterial anastomosis; in such cases, PTA with an appropriate-sized balloon is effective.

If arterial inflow demonstrates no disease at this point and if flow via the graft remains inadequate, the venous track is reevaluated to identify recurrent stenoses.

The presence of stenosis at the same location as a lesion that was previously treated with PTA is an indication for endovascular stent placement after PTA. Stent deployment is performed on an individual basis after conferring with the referring vascular surgeon, bearing in mind the best interest of each particular patient.[45]

Post-Procedure
Results

Most series define success as complete recanalization of the thrombosed graft such as to allow at least 1 successful dialysis session within 24 hours of the procedure. Success rates reported in the literature have been similar, ranging from 71% to 100%. Long-term results of graft recanalization are usually evaluated by calculating primary and secondary patency rates from Kaplan-Meier life tables.
Patency rates

The primary patency rate is defined as the time between the initial procedure and a second procedure that is needed to preserve graft patency. Overall results show primary patency rates of more than 32% at 30 days, more than 30% at 6 months, and less than 25% at 1 year.

Secondary patency rate refers to the cumulative time from the initial procedure to the abandonment of the graft or a surgical revision. Reported secondary patency rates have been significantly higher than primary rates, reaching more than 90% at 30 days, more than 80% at 6 months, as high as 80% at 1 year, and slowly decreasing thereafter.

It is noteworthy that success rates are similar for prosthetic polytetrafluoroethylene (PTFE) grafts and forearm native fistulas, although most interventional radiologists agree that declotting a native fistula is technically more challenging than declotting a graft. In addition, the results clearly appear to be more durable after recanalization of a forearm native fistula, although repeat intervention is much more common for prosthetic grafts and upper-arm fistulas.
Nonsurgical versus surgical interventions

Technologic progress in the field of interventional radiology and device manufacturing has allowed a large number of procedures to be performed without open surgery. One of the fields in which this approach has flourished is the treatment of failing and thrombosed dialysis access. Direct comparison with the surgical treatment of graft thrombosis is not easy, and when patency rates are involved, the comparison is meaningless, because the surgical literature determines patency from the time of graft placement or fistula creation, whereas assessment of nonsurgical interventional procedures begins from the point of failure or thrombosis. Very few small, randomized trials have been conducted comparing the results and failures of nonsurgical interventions and surgical procedures.

With the exception of certain stent locations, most nonsurgical interventional procedures do not prohibit future surgical revision if and when needed. Nonsurgical procedures can also be used to recanalize the access site without sacrificing any fragment of the venous outflow, thereby prolonging the use and overall life of the access.

Several percutaneous techniques have been studied, with comparable results. In the literature, sufficient evidence has proven that nonsurgical interventional treatment of hemodialysis access failure and thrombosis provides good and durable results when performed by experienced operators. This assessment has been supported by the US National Kidney Foundation's Kidney Disease Outcomes Quality Initiative guidelines for graft maintenance.
Complications

Overall complication rates are low—typically, 0-16%. Complications include arterial emboli (1-7%); post–percutaneous transluminal angioplasty (PTA) flow-compromising ruptures (2-5%; the rate can be higher in native fistulas of upper arm [15%]); fluid overload or pulmonary edema; reactions to the contrast agent; extravasation hematomas at puncture sites of previous dialysis procedures; infection; and death (very rare). Death may result from cardiac arrhythmia, pulmonary edema, or a reaction to the contrast medium.

Although clots may migrate into pulmonary circulation, clinically evident pulmonary embolism has been reported in only 6 cases; however, pulmonary embolism may occur with native fistulas. This complication is extremely rare during thrombolysis of hemodialysis access grafts.
Management of complications

Most complications are treated by the interventional radiologist during the procedure. Arterial emboli are retrieved with an embolectomy or with the use of a Fogarty balloon thromboaspiration, or they are treated with local infusion of a thrombolytic agent (urokinase [UK] or tissue plasminogen activator [t-PA]). Although there is a theoretical risk of serious complications during thrombolysis with any of the thrombolytic agents (UK, streptokinase, t-PA), life-threatening bleeding complications are extremely rare.

Post-PTA ruptures have been treated successfully with prolonged balloon inflation and the deployment of uncovered and, more recently, covered stents, as needed. If needed, stent deployment may be used to keep the pathway toward the right atrium patent. These options usually allow completion of the procedure and salvage of the arteriovenous graft or native fistula.

Fluid overload and pulmonary edema can be avoided by providing hemodialysis via a temporary catheter in all patients who do not undergo dialysis for more than 72 hours before the recanalization procedure. When fluid overload occurs during or after the procedure, it can be treated medically with appropriate methods, including oxygen therapy and the administration of diuretics.[46]
Conclusion

With the advent of new devices and the continuous improvement of existing devices, the percutaneous treatment of failing and occluded dialysis access will continue to improve in the future. The role of the interventional radiologist is changing. The radiologist's role has changed from that of an angiographer who makes the diagnosis into that of a physician who treats patients with chronic renal failure in coordination with the nephrologist and the vascular surgeon.

More on "Looking UP": Aurora Borealis

2012-01-25T06:54:00.000-06:00

One thing these eyes have wanted to see before they fail is what some call the Northern Lights, My Grandfather was from Ireland, he told my Mother of them, and she told me, a common bond was that neither she nor I had seen them except in pictures, but Grandpa had seen them, if you talk at length to Grandpa you'd find he loved all the natural beauty he'd even seen, he passed that onto those who listened. The Aurora Borealis has been especially active in January, and I see daily postings about the beautiful lights displayed across a sky I can't see, but it doesn't mean I don't know and cherish the beauty of it's existence, here is one find I came across:

Alaskans will be witnessing much more aurora activity in the near future, said University of California, Los Angeles geophysicist Yuri Shprits, who studies the potential impacts of solar storms on satellite systems.

A storm happens when massive amounts of radiation from solar flares hit the Earth's magnetic field.

"For a long time, we had one of the quietest periods of electromagnetic activity," Shprits said in a phone interview from Los Angeles. "After such a long time the sun is waking up and it's big news."

It can be dramatic.

For the past week, solar storms of a magnitude unseen in the last decade have been raging in space, according to NOAA's Space Weather Prediction Center.

The effects have been rolling down to Earth's atmosphere in the form of strong auroras for days, lighting up Northern skies with sometimes ghostly, sometimes explosive displays.

Solar radiation from a much larger geomagnetic storm than the one the Earth has experienced in the past week could have lasting damage to satellite systems "for years" after the storm ended, Shprits said.

People don't realize how much they depend on satellites for technology, navigation and even communicating with ATM machines, he said.

"We should be more aware of (geomagnetic storm activity)," he said. "We'll see much more soon."

Alaskans have a front seat to a solar storm's most obvious earthly manifestation

For a Fairbanks crew of self-described "Aurora Chasers," Tuesday night's predicted aurora was akin to a Christmas present from the solar system.

Ronn Murray, a sleep-deprived Fairbanks photographer and new dad to a 3-week-old son, planned to spend the night outside in -25 degree temperatures.

Murray's wife had given the plan her blessing, he said.

The University of Alaska Fairbanks Geophysical Institute predicted "highly active" aurora displays visible over many parts of Alaska, from Barrow to Ketchikan, for Tuesday night. The display is expected to taper off Wednesday and Thursday.

"I've been chasing for five years," Murray said. "And this is the best I've ever seen."

Murray and a small cadre of other hard-core aurora photographers who met on Twitter and Facebook gather most nights when a display is predicted.

They seek spots - like local favorites Ester Dome and Murphy Dome - that offer a wide blanket of sky. Sometimes that means driving 30 or 40 miles out the Steese Highway.

Then, in temperatures that can dip into the minus 40s, they watch and photograph from 8 p.m. until 6 or 7 in the morning, huddling inside cars to get warm and snacking on beef jerky and granola. The trick is "many, many layers" of clothing, Murray said.

He takes hundreds of images per night, some stills, some time lapses, shooting with a professional-grade Canon SLR camera and selling his images on his website.

The group - which numbers between three and a half-dozen - planned to head up the Dalton Highway Tuesday night, Murray said, hoping that a partly-cloudy forecast wouldn't materialize.

During long nights of photographing auroras, the lights are occasionally overwhelming enough to get Murray to stop clicking the camera.

Sometimes, he said, he just stops and looks up

Why we wake up

2012-01-22T08:19:00.000-06:00

"When was the last time, you ever saw the sunrise?"

A Great Song by Eddie Vedder: "Breathe"

http://www.youtube.com/watch?v=ZHRuS6X3JpU&feature=related

Reptile runs for President in our Society

2012-01-22T04:50:00.002-06:00

Amazing division of Americans, in Fall of 2008 slight collapses felt by the people, was in fact a huge earthquake beginning but concealed by the financial houses of Wall Street and the very best of the BIG BANKS with the help of Geitner's great cover up (remember now he got rewarded for his efforts...he's indispensable or so it appears).

2009, the quake has totally devastated the land knocking out the housing industry in one total powerful swoop, Carpenter's, electricians, plumbers, concrete, heating and cooling, roofer's, real estate attorneys, realtors, builders, general contractors, all effected as this industry was ground to a halt, 1/2 built houses littering the horizon month after month no one works on them, these projects have become ghost towns, and there are everywhere across the United States.

There's an election campaign in full swing: Bush and Chenney (Dumber & Dumb still in office from an 8 year reign of terror who allowed this horseshit to happen come forward with their partial truths, Banks are failing must be bailed out, Wall Street has gone berserk, Banks stop lending, existing home values begin to tumble, the Automotive's are in trouble as well, they all need bailing out. The current campaign has two Senator's running against each other, for the first time ever the two campaigners are pull into the loop..."all proclaiming at that time "put the party aside" The best alleged economic advisers are pulled into the core of the loop, numbers analyzed, crunched, solutions proposed to the people and proposed to the future elected President whichever it might turn out to be. President Obama is elected as President months after the first segments of the agreed upon bailout have been implemented, he implements more as the middle class and lower class households affected by mass layoffs of employees across the land sink under the weight of changed household incomes.
His first and main problem was he was actually the best and most correct person to handle this situation, but his one flaw was he was not aggressive enough from the beginning, aggressive of the highest kind was needed, and a very swift action to be taken with various laws being implemented, instead they got side-tracked and passed these new plans and laws which dates extended way out into the future (only allowing Opponents to try and over turn or chop the plans into animals no longer recognized). AND THEN ANOTHER ELECTION BROUGHT A MAJORITY REPUBLICAN (aka: REPTILES)House (This should known as the GREATEST AMERICAN TRAGEDY)into our previously sensible Congress.
So now for a couple of years no progress has been made, the house blocks every bill, and nothing gets signed into law, obstructing the President has become their full time Hobby, and these REPTILES have thought of no common man since they ran for office, it has even come to light that they signed a pledge before running for office (EVERY REPUBLICAN OUT IN CONGRESS) with a private powerful sector, swearing they'd never vote for tax increases to protect the very wealthiest members of the country from paying a proportionate share of taxes instead of being sheltered as they have been for light years. This Pledge is morally and ethically wrong, no member of Congress, No Senator, No President should give promises in writing to an outside party, it has totally made them corrupted in their representations of the American People., if I could I would deport these members to Siberia, Russia for the very highest of TREASONS AGAINST THE AMERICAN PEOPLE!
And now they have the nerve to promote " The Newt", one of Busc/Chenney's original Reptiles for a Presidential Election, as my GrandPa from Ireland would have coined it: " The man is a snake in the grass"!

A very good tune by Eddie Vedder: Society: http://www.youtube.com/watch?v=Cy6iwP9Ux3A