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Stony Brook experts using minimally invasive technique for dialysis

Drs. Apostolos Tassiopoulos, left, and Mohsen Bannazadeh, of

Drs. Apostolos Tassiopoulos, left, and Mohsen Bannazadeh, of Stony Brook University Hospital, will use a new technique that promises to create a channel in the arm for a copious flow of blood without the need for minor surgery when performing kidney dialysis. Credit: Andrew Theodorakis

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A little-known public fact about kidney dialysis is that hundreds of thousands of patients whose blood is cleansed via the mechanical process must first undergo a surgical procedure to create access in the arm for the dialysis needles.

Now, medical experts at Stony Brook University Hospital have begun using a minimally invasive technique that promises to create a channel in the arm for a copious flow of blood without the need for minor surgery. The new method increases the odds against scar tissue formation, a problem with the conventional surgical procedure.

“With the traditional methods, what we used to do is make an incision in the patient’s arm and take a vein and mobilize it from its original position,” said Dr. Apostolos Tassiopoulos, a professor of surgery, referring to moving a vein in the arm into a new position where it is linked with an artery in the creation of a channel — a fistula — to increase blood flow.

“The problem is that the mobilized vein sometimes becomes scarred,” he said, noting that scar tissue blocks access and delays dialysis. Many patients require the same surgery on the opposite arm.

A fistula is the joining of an artery and vein in the arm to create a large conduit to handle the heavy turbulence of blood that flows out of the body and into the dialyzer, where impurities are filtered before being returned to the body’s circulation. A nurse or technician places two needles into a patient’s arm at the beginning of hemodialysis to accommodate outflow and inflow.

Finding new and efficient ways to aid patients on dialysis are important, Tassiopoulos said, because the ranks of people with chronic kidney disease continues to grow, often the result of hypertension and diabetes, two conditions that damage kidney function. The twin bean-shaped organs, purplish in color, filter the blood by removing wastes and excess water. 

An estimated 500,000 people in the United States are on hemodialysis, according to the National Kidney Foundation. The intervention performs the job that can no longer be done by the two organs.

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The aim of creating a fistula is to maximize the amount of blood that can pass from the patient into the dialyzer, explained Tassiopoulos, who is also chief of vascular and endovascular surgery at Stony Brook. Creating a conduit in the arm not only makes a wider opening, it also increases the channel’s strength, he said.

With the new technique, Tassiopoulos treats patients with a method that avoids surgical knives and post-surgical sutures. He enters a patient’s arm with ultrathin wires that are guided through the superhighway of crisscrossing veins and arteries to create a new channel for dialysis.

“The formal name is percutaneous endovascular fistula creation,” Tassiopoulos said.

Instead of an incision, Tassiopoulos relies on “micropuncture” to insert his guidewire to reach the ulnar vein in the arm. The wire is gingerly moved to the brachial vein near the “bend” in the arm. Then, a second guidewire is inserted, also via micropuncture, to reach the brachial artery, which forks into the ulnar artery.

When both wires are in position, thin catheters, which contain magnets, are inserted in both vessels. Magnetic energy helps the catheters align the vein and artery. An electrode in one of the catheters is activated to release radio-frequency energy, which quickly creates a channel between the artery and the vein. The catheters and wires are removed and the channel — a fistula — is the result, an opening made wider and stronger to accommodate kidney dialysis.

“It took about two hours. I was in and out with just two tiny holes in my arm,” said Jahan Khalid, 69, of Lake Grove, who recently underwent the procedure. “You can hardly see them anymore. Going to the dentist is more painful than this procedure.”

He said it will take about three months for the fistula "to mature," which means becoming strong enough to support hemodialysis.

Khalid, an MRI and CT technologist at the Northport VA Medical Center, has chronic kidney disease, the result of high blood pressure and diabetes. He has not yet begun dialysis. When he does, Khalid will be among a small coterie of patients whose link to a dialysis machine will rely on a conduit created by a novel method.

“We have already treated four patients, and two others will be treated soon,” Tassiopoulos said, noting that he and his team at Stony Brook were the first on Long Island to utilize this new technology to aid kidney dialysis patients.

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