Houston, we have a dialysis access problem

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Karl Illig (left) and Eric Peden

The concept of dedicated vascular access centers fuels a turbocharged Texan tussle with Karl Illig, MD, of Flow Vascular Institute in Houston, taking on Eric Peden, MD, an associate professor of cardiovascular surgery at Houston Methodist Hospital, in a no-holds-barred debate on how best to deliver longitudinal patient care. The question is: who will patients call with “Houston, we have a (dialysis access) problem”?

Illig tips his hat at renowned vascular access educator John Ross, MD, and “his greatest contribution”—the creation of the concept of the total dialysis access provider and total dialysis access center. Ross’ clinical career culminated in the creation of the Dialysis Access Institute in Orangeburg in 2013, and Illig is an unapologetic advocate for similar comprehensive dialysis access centers as the model to deliver the best patient care. In a presentation titled “Dialysis access in the 21st century: A call to arms” Illig is categorical about his message to renal care physicians providing dialysis services: “You do it wrong—patients die early. You do it right—quality and quantity of life significantly improve.”

His core message is that with no dedicated plan, training and staff, patients face the prospect of every event occurring in isolation, resulting in excessive catheter contact time, which leads to higher morbidity and mortality. “This is the perfect area of medicine to change care from ‘technique-driven’ to ‘problem-driven’ care,” he says.

The total dialysis access center concept to reinvent the delivery model consists of “several, overlapping and interlocking ideas: one-stop shopping for creation, maintenance, complex salvage, hemodialysis and peritoneal dialysis.” Such centers aim to draw on surgery, endovascular interventions, hybrid procedures and nephrology. This is a designed counterpoint to the accepted format of the system being geared towards “big cases.” In the main, “our patients are sick—but procedures are very low-risk,” avers Illig.

“All operating rooms are set up for surgery and endo[vascular] seamlessly,” he adds. “To the nephrologist, we say: ‘just send [the patient].’ There is a near-same day service. There is no set schedule, walk-ins are welcome; we have imaging, anesthesia, labs, clinical trials and operating rooms under the centre’s control. There is no waiting.”

Longitudinal care sits at the heart of such centers that only provide dialysis care. Illig notes that there is a sense of a plan for all patients that includes recognizing when plan A is not working and identifying when maturation is taking too long. “Of course, the devil is in the detail. How can you do this in a cost-effective manner? At the end of the day, your income must meet your expenses,” he says.

In favor of comprehensive centers

Peden’s riposte is that the most beneficial aspect to practicing in a hospital system is that you can provide truly comprehensive care. “No matter how sick the person, no matter what their other medical troubles are, there are additional resources available at the hospital setting that are simply not available at some outpatient settings,” he states.

Peden acknowledges that freestanding centers offer a variety of advantages for what he terms “garden variety” vascular access care. “In the hospital setting, we are certainly not as limber as the freestanding access centers, which are set up to provide same-day service. For some emergent procedures, such as clotted fistulas or grafts, I think it is better for patients to go to a freestanding centre because the convenience factor is impossible to overcome. For standard creations, I think that is probably reasonable as well, but if there is a bleeding complication, or a person needs transfusion, then you probably need to be in a bigger facility,” he continues.

“In other scenarios, when things are more complicated—when patients have potassium issues, or heart issues such as rhythm problems, or any other serious conditions that dialysis patients have—then care really cannot be provided safely at the access center. Heaven forbid there are complications, those really need to be managed in a hospital,” he says.

“No matter how sick the person, no matter what their other medical troubles are, there are additional resources available at the hospital setting that are simply not available at some outpatient settings.”

His argument relies heavily on the point that a tertiary care hospital is capable of providing heart-lung support or “whatever is needed.” Other complications, such as bleeding, clotting or embolus, are also very difficult to manage if providers do not have access to full surgical facilities, or additional equipment or tools like snares, embolectomy catheters and surgical techniques that can be provided in a hospital operating room or interventional suite that may not be available at a freestanding center.

“Many freestanding centers do not have covered stents, which is probably an error because if they have rupture and bleeding, those things have to be dealt with—occasionally with a stent graft,” Peden adds. “If all you can do is put a balloon up, that is a problem, because it means patients are eventually sent to a hospital or clinic, such as where I work, and then we take care of it through the emergency room and operating room. The question is: what degree of complexity does the person need to have that they might need more support?

“My focus is complex access. So, I take care of a lot of complicated patients that need big, extensive revisions that I think would be really challenging to do in standalone dialysis access centers. At the hospital, we are able to offer more definitive care. A great example is someone I am treating who has had angioplasty upon angioplasty every few months for stenosis of the central venous lesion. To alleviate the thoracic outlet compression, we might surgically remove a rib or clavicle, reconstruct the subclavian vein and fix the aneurysm, but that could turn into a much bigger deal that simply cannot be offered in access centers. There are some bigger and more complicated procedures that definitely need to be done in surgical programs like mine.”

Illig responds to underscore that, at Flow Vascular, operations are performed in an (arteriovenous access-only) hospital, and that their office-based labs are used for office visits and “very straightforward” elective fistulagrams.

Both agree that for a fairly clear-cut, urgent procedure, a freestanding dialysis access center is probably the most convenient first port of call for patients, all the way from simple things, such as parking, to path to care and speedy treatment being easier to navigate than in a hospital setting where the logistics and requirements can be substantial, especially in the COVID-19 era. Further, access centers plan for same-day evaluation and procedure, whereas there are generally days or weeks between the two in a hospital setting.

Multidisciplinary care

Illig is insistent that at freestanding dialysis centers “we all take care of all patients, and communication is key.” He further asserts: “There are well-trained physicians who want to be there and do this. The care delivered is based on a high degree of standardization and skill arising from repetition. Academic and educational focus takes centre stage, and the same team is in the operating room every day.”

This enables surgeons, interventionalists and nephrologists “all working truly together in one place—not just paying lip service from each separate office.” The key issues other than interdisciplinary decision-making are same day service (or close to it), getting everything needed in one step on one day, and zone defense, where all patients are cared for by the team at hand rather than waiting for “their” person.

Such centers, Illig offers, also “allow for control of your own procedure space, which is, incidentally, set up for both surgery and endovascular intervention in all cases. We just do what is best for the problem at hand rather than what we happen to have a certificate on the wall for.”

Peden aims to land a direct hit when he notes that, barring a few well-run freestanding access centers, many do not have multidisciplinary teams on hand. “There are centers with just vascular surgeons performing both open and endo procedures. So, although they carry out both types of procedure, I am not sure that is a multidisciplinary conversation unless you are talking to your ‘endo’ self and your ‘open’ self, back and forth. Of course, there are some centers where transplant, surgery and radiology work really well together and provide comprehensive care. But many vascular surgeons of my generation and younger provide the full gamut of treatments and usually do most of the work themselves,” he notes.

Outcomes

Another pertinent question is: does setup have a bearing on outcomes? According to Illig, it does. “A recent audit of 671 cases reviewed over a six-month period showed that overall infection rate was 2.7% and serious infection rate was 0.6%,” he reports. In addition, the mortality rate was found to be 0.5% (including one self-withdrawal), results for arteriovenous fistula 30-day patency rate (not maturation) were as follows: radiocephalic=100% (n=4); brachiocephalic=95%; brachiobasilic first stage=89%; brachial vein transposition second stage=89% (77% overall); brachial vein transposition single stage=82%. Illig notes: “They also placed 24 HeRO grafts (Merit Medical) with a 30-day patency of 94% and a 30-day infection rate of 4%. The Flow Vascular team also placed 37 peritoneal dialysis catheters with a 30-day function rate of 96%. The center also recorded catheter prevalence rates of between 4% and 9%.”

Peden weighs in to say that the results from his hospital “are similar”—but warns against easy comparisons. “Complication rates might actually be higher in a center like mine only because the low-hanging fruit in terms of the easier procedures in healthier patients are being done in freestanding centers, and more complicated procedures, such as in a stroke victim on oxygen and anticoagulation-dependence—those things come downtown,” he says.

He also counsels against assuming the catheter prevalence rates from Flow Vascular are indicative of all freestanding centers. “I think [these rates] are really dialysis center-to-dialysis center-dependent and are heavily influenced by how that centre is run, and the referral patterns they have. The numbers you say are good and should be what people are trying to achieve i.e., less than 10% catheter rates.”

Leftover surgery at midnight

Illig maintains that dialysis access deserves more respect; “other than venous disease, it is the most common problem our patients have. AV [arteriovenous] access in most places is a low-priority operation, including at universities that I have been affiliated with. It brings to mind surgery at midnight—you get bumped by everybody else. Typically, it is the junior resident helping out as nobody else wants to do it and care received can be speciality-driven, with usually only surgical options available.”

Peden counters sharply by stating: “Of course, Friday at five, where is the person going to go? If they are knocking on the access centre door, they are going to be knocking for a while because nobody is coming until Monday morning. Whereas we are available 24/7, right? This weekend, my partner was doing thrombectomies all weekend, followed by temporary catheter placement for urgent dialysis, because those problems happen.”

“AV [arteriovenous] access in most places is a low-priority operation, including at universities that I have been affiliated with. It brings to mind surgery at midnight—you get bumped by everybody else.”

To the specific charge of surgery at midnight, Peden replies: “I might say better midnight than Monday morning! Because, in many access centers, patients are going to be given a bottle of kayexalate and told ‘good luck over the weekend, see you on Monday morning,’ which is a real problem. In my center, we have two operating rooms dedicated to dialysis access, every day, Monday through Friday, and for emergencies as they arise at the weekend.”

But, he agrees there is legitimacy to the allegation of being bumped. “Of course, there are other hospitals where access is not really a primary focus. For sure, patients are going to have to wait until all the gallbladders, hearts and traumas are done, which sometimes means a patient is waiting for days and days to have the procedure…that is clearly not a service to the patient. And that is why, if it is straightforward, going to an access centre—where that is their focus—is helpful.”

Established systems best serve dialysis patients

Peden’s memo to colleagues reads: “Honestly, dialysis patients are best cared for where there is a system in place, so the two scenarios of access centre and hospital-provided care do not have to be exclusive. I work with lots of people at access centers. I will absolutely send patients to access centers if they need a catheter exchange or such like, which can be quickly treated. They really like coming to these centers and the swag they provide.

“And then, if there are more complications, they will come back and see me, or if they have a preference for more anesthesia or more sedation. So, the two do not have to live in exclusivity or competitive spirit. I think there are many sick people out there who need as much help as they can get and both places can provide good care. But I think there will always be a role for big facilities like mine to help take care of people with more complicated troubles.”

Peden and Illig both sign up to the view that patients are best served by a team taking care of people with dialysis needs as efficiently as possible, and concede they simply emphasize different strategies of war to achieve the same goal. The essential principle, they agree, is that everyone involved in dialysis access should take it seriously and “be access whisperers. Remember, doing it right saves lives”.

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