Radiation hand exposure during restoration of flow to the thrombosed dialysis access graft

Interventional Nephrology: Opportunities and Challenges

The nephrologist has a pivotal role as the leader of multidisciplinary teams to optimize vascular access care of the patient on dialysis and to promote multidisciplinary collaboration in research, training, and education. The continued success of interventional nephrology as an independent discipline depends on harnessing these efforts to advance knowledge and encourage innovation. A comprehensive curriculum that encompasses research from bench to bedside coupled with standardized clinical training protocols are fundamental to this expansion. As we find ourselves on the threshold of a much-awaited revolution in nephrology, there is great opportunity but also formidable challenges in the field - it is up to us to work together to realize the enormous potential of our discipline.

Reduction of operator radiation exposure using a passive robotic device during fluoroscopy-guided arterial puncture: an experimental study in a swine model

Background

Vascular interventions imply radiation exposure to the operating physician (OP). To reduce radiation exposure, we propose a novel passive robotic device for fluoroscopy-guided arterial puncturing.

Methods

X-ray dose rates were measured for a total of 30 fluoroscopy-guided puncture femoral arteries in 15 pigs. Fifteen punctures were performed with the device while the other 15 were performed without the device by an interventional cardiologist with 10 years of experience. Parametric t test was used.

Results

The success rate with the device was 100%. Overall, the OP received more radiation (0.41 mSv/h) as compared to the assistant (0.06 mSv/h) (p <  0.001) and, amongst OP’s body parts, hands received more radiation than other body parts (p <  0.001). The radiation dose rate to the OP’s hands during arterial puncturing performed manually without the device was 0.95 ± 0.25 mSv/h whereas it was 0.14 ± 0.006 mSv/h using the device, resulting in an 85% reduction (p <  0.001). For the head, the dose was reduced from 0.16 mSv/h to 0.08 mSv/h (50% reduction, p <  0.001), and for the dominant arm, from 0.12 mSv/h to 0.07 mSv/h (42% reduction, p <  0.001). The fluoroscopy time was reduced from 4.5 ± 0.15 min to 4.3 ± 0.11 min device (p = 0.002).

Conclusions

In a swine model, fluoroscopy time and radiation exposure for the OP puncturing femoral artery were significantly reduced by using the passive robotic device.

Role of interventional nephrology in the multidisciplinary approach to hemodialysis vascular access care

Dialysis vascular access planning, creation, and management is of critical importance to the dialysis patient population. It requires a multidisciplinary approach involving patients and their families, dialysis facility staff, the nephrologist, the surgeon, and the interventionalist. With the emergence of interventional nephrology as a subspecialty of nephrology, the nephrologist is increasingly providing both the nephrology and interventional aspects of care, and in some areas, the surgical functions as well. Most of these interventional nephrologists work in freestanding outpatient dialysis access centers (DACs). Large clinical studies published over the past 10 years demonstrate that the interventional nephrologist can manage the problems associated with dialysis access dysfunction effectively, safely, and economically. A recently published study based upon United States Medicare claims data in which a DAC patient group (n = 27,613) and a hospital outpatient department patient group (HOPD group; n = 27,613) were compared using propensity score matching techniques showed that patients treated in the DACs had significantly better clinical outcomes (P<0.001). This included fewer vascular access-related infections (0.18 vs. 0.29), fewer septicemia-related hospitalizations (0.15 vs. 0.18), and a lower mortality rate (47.9% vs. 53.5%).

Sonography characteristics of the intra-graft thrombus: association with procedure success and procedure time of percutaneous transluminal angioplasty for thrombosed prosthetic dialysis graft

Percutaneous transluminal angioplasty (PTA) for thrombosed dialysis graft is both difficult and time-consuming that may increase radiation exposure. A predictor of PTA success and procedure time has not been identified yet. Sonography data and the PTA results of 88 grafts were reviewed retrospectively. The echogenicity of the majority of the intra-graft thrombus and the presence/absence of thrombus free space in the grafts were examined. The association between the sonography findings and PTA procedure success and procedure time was analyzed. The echogenicity of the intra-graft thrombus and presence/absence of thrombus free space were the major determinants of procedure success and procedure time. Higher intra-graft echogenicity and lack of thrombus free space were associated with more procedure failures (p < 0.01 vs. p = 0.04) and longer procedure times (p = 0.03 vs. p < 0.01). Thrombi from occluded dialysis grafts may differ in resistance to mechanical/pharmacological thrombolysis. Sonography characteristics of the intra-graft thrombus may help to differentiate them.