I want to express my sincere thanks for the Lifetime Achievement Award given to me at ASDIN 2026 annual meeting in Orlando last weekend.  Bharvi Oza-Gajera offered me the chance to speak at the podium but I declined out of respect for keeping the meeting on time; I hope the program chairs appreciate this consideration.    

Please indulge me  now to let you know that this award is greatly appreciated at my retirement. ASDIN is a wonderful community of professionals dedicated to the “lifeline” of our patients. This award is a high honor for me.

I remain hopeful that  the current  low numbers of new nephrologists are just a cycle and that we continue to encourage  and inspire the young and bright future talent that our specialty is rewarding in many ways.

Godspeed ASDIN.

Jeffrey Hoggard MD

I want to express my sincere thanks for the Lifetime Achievement Award given to me at ASDIN 2026 annual meeting in Orlando last weekend.  Bharvi Oza-Gajera offered me the chance to speak at the podium but I declined out of respect for keeping the meeting on time; I hope the program chairs appreciate this consideration.    

Please indulge me  now to let you know that this award is greatly appreciated at my retirement. ASDIN is a wonderful community of professionals dedicated to the “lifeline” of our patients. This award is a high honor for me.

I remain hopeful that  the current  low numbers of new nephrologists are just a cycle and that we continue to encourage  and inspire the young and bright future talent that our specialty is rewarding in many ways.

Godspeed ASDIN.

Jeffrey Hoggard MD

https://sites.google.com/site/abigailsarticles/august-2025-articles

https://sites.google.com/site/abigailsarticles/august-2025-articles

We have appealed all of the denials with extensive comments/resources/literature (including it being an official CPT code, Medicare/Medicaid covering it, etc) but they have upheld their denial every time.

Anyone else having similar issues? How else can we handle such denials?

https://sites.google.com/site/abigailsarticles/august-2024-articles

  I am working both general OP and Inpt Nephrology and doing Procedures in the hospital.  I've seen that the Vascular Surgeons do a Consult on the patients they get asked to do procedures and obviously do a separate procedure note. This is an opportunity to bill for 2 services and it actually is useful so one gets to know the patients and anticipate particular issues and avoid complications, i.e. having had a device in the past on either neck, sensitivities to moderate sedation , review labs etc 

  However If they place a consult for me - not my own patient I'm rounding on - I don't think there can be 2 nephrology inpatient consults, and I wouldn't think that we can do a consult as Vascular Surgery as we are Not.  so the Question: 

  a) Is there a code for Interventional Nephrology inpatient or for that matter outpatient consultations ? 

  b) Is there anyone else facing this issue and how are you addressing it ? 

Thanks 

Fernando 

Sometimes this happens naturally - as in cases where the cephalic vein does not connect with the basilic system via the median ante/cubital bridge (maybe 10% of patients), but frequently the upper arm cephalic vein diminishes in size, flow and apparent usefulness with diversion of flow at the antecubital fossa (into the deep system via the perforating branches, and the basilic system via the median cubital - "MAC"), then via the first lateral branch above the antecubital fossa, where it drains to the veins of the profunda brachii. Above the first third of the arm it is also frequently deep.

To make the upper arm cephalic vein extension of a forearm fistula more usable, I frequently do an "antecubital disconnection" via a small incision just media to the cephalic, and over the first part of the median antecubital. After test clamping the MAC to make sure the fistula maintains its thrill, the MAC is doubly ligated and divided to expose the deep branch, which is then also skeletonized, doubly ligated and divided, making the cephalic the main outflow conduit and completing the disconnection. I generally skeletonize the cephalic thoroughly, as there may be several smaller deep branches in the area. This maneuver can be completed the same time at the wrist fistula, adding 20-30 minutes to the case.

A more ambitious modification is superficialization of the cephalic vein in the upper arm, not generally done at the same time as the wrist fistula, but always including the antecubital disconnection. If a robust median antecubital is left in place to drain the forearm to the low resistance basilic, the traumatized higher resistance cephalic vein may sclerose down and fail to develop, leaving you with nothing for your pains and promises. 

Sometimes this happens naturally - as in cases where the cephalic vein does not connect with the basilic system via the median ante/cubital bridge (maybe 10% of patients), but frequently the upper arm cephalic vein diminishes in size, flow and apparent usefulness with diversion of flow at the antecubital fossa (into the deep system via the perforating branches, and the basilic system via the median cubital - "MAC"), then via the first lateral branch above the antecubital fossa, where it drains to the veins of the profunda brachii. Above the first third of the arm it is also frequently deep.

To make the upper arm cephalic vein extension of a forearm fistula more usable, I frequently do an "antecubital disconnection" via a small incision just media to the cephalic, and over the first part of the median antecubital. After test clamping the MAC to make sure the fistula maintains its thrill, the MAC is doubly ligated and divided to expose the deep branch, which is then also skeletonized, doubly ligated and divided, making the cephalic the main outflow conduit and completing the disconnection. I generally skeletonize the cephalic thoroughly, as there may be several smaller deep branches in the area. This maneuver can be completed the same time at the wrist fistula, adding 20-30 minutes to the case.

A more ambitious modification is superficialization of the cephalic vein in the upper arm, not generally done at the same time as the wrist fistula, but always including the antecubital disconnection. If a robust median antecubital is left in place to drain the forearm to the low resistance basilic, the traumatized higher resistance cephalic vein may sclerose down and fail to develop, leaving you with nothing for your pains and promises. 

We want to foster ongoing dialogue, so feel free to make comments below.

Cases and Presenters:

Another Percutaneous Cuffed Cather Not Working
presented by Steven May, MD, Tamworth, New South Wales, Australia

PD Catheter Complications after Percutaneous Placement
presented by Mark London, MD, Dialysis Access Institute, Orangeburg, South Carolina, USA

Panelists: Ted Saad, MD and Stephen Ash, MD

Moderators: Amy Dwyer, MD and Anil K. Agarwal, MD, 
Chairs, ASDIN International Outreach and Development Committee

https://twitter.com/ASDINNews/status/1593704588007264257?s=20&t=5vl9qqb-jfWPMqviSQJePw

https://twitter.com/ASDINNews/status/1563277438976933894

https://twitter.com/asdinnews/status/1584524623047454720?s=46&t=Iczj-zXMrJa3cH7V_SQUGw

https://sites.google.com/site/abigailsarticles/august-2022-articles

Marc Webb, MD FACS, Detroit - 734-502-1239

Marc Webb, MD FACS, Detroit - 734-502-1239

The Hull article is being presented tomorrow at the SIR Annual Scientific Meeting in Boston. 

https://sites.google.com/site/abigailsarticles/june-2022-articles

In the last 20 some years of my IN career, I have come across few patients with AV accesses created intentionally or unintentionally ipsilateral to axillary LN dissection (+/- XRT, often associated in this case with axillary vein stenosis). The outcome was (unanimously) the development of arm swelling, namely significant lymphedema, leading (with only 1 exception in my experience) to the ligation of the access. Some entertain the option of a "low flow system". I have not seen that work... 

Logically speaking, an ipsilateral HeRO graft, should not lead to the same outcome (from the severity standpoint), since it is bypassing the outflow veins/drainage system of the ipsilateral UE. I assume, there is still a concern of developing central vein stenosis from the outflow component of the HeRO graft, but I don't see that being a major deterring factor. 

I came across a situation like that today, the patient has an occluded right innominate vein and widely patent left sided central veins (left UE venogram was not performed) where an extensive axillary LND was performed. A left IJV TDC was placed and I am exploring the option of a HeRo on that side.

Has anyone done that? What was the outcome?

Thx

Tony Samaha, MD

Cincinnati, Ohio

This patient had undergone multiple AV access placements on his right arm. When I examined the current AV graft of his right upper arm, it was found to end its longevity, and no more AV access placement was feasible on his right arm. In contrast, he had never had vascular access surgery on his left arm because his physician emphasized that any AV access should not be placed on his left arm to avoid coronary steal syndrome. In fact, the patient underwent CABG using the left internal thoracic artery. I'd like to recommend a new AV access creation in the left arm, but the patient is afraid that he will die of AMI if he gets AV access in his left arm. So, I'm here to ask you for advice.

First,

Would it lead to coronary steal syndrome if I created an AVF or AVG on his left arm? How high is the probability for the patient to encounter a coronary steal in such a case?

Second,

If an AVF creation was planned in the left arm, would limiting blood flow, for example, to 600-800ml/min or less help to reduce the risk of coronary steal?

Third,

When a patient with a CABG history needs an AV access creation, should we always confirm which graft for CABG was used and which way of CABG operation was performed?

I'd like to appreciate your comments.

Hyungseok Lee, MD, FASDIN

Hallym University Sacred Heart Hospital, South Korea.

pcsacred@gmail.com

Our center is looking to purchase another ultrasound for dialysis access procedures and flow measurements.  Currently we have a nice GE Logiq and also a really old Sonosite.  Any suggestions on a portable U/S machine that is good quality and relatively affordable?  Any thoughts on the Butterfly?

ORIGINAL POST:

From: Varun Kumar Bandi

Respected seniors and colleagues

We have a 45 year old woman with CKD VD due to CIN and multiple fistula failures. Left RC was primary failure due to faulty technique and immediately left Brachio Cephalic AV fistula was done which failed in 2 months. She underwent right brachiocephalic AV fistula 6 months back but had a faulty cannulation with Hematoma and cellulitis. Clot evacuation with pseudoaneurysm repair done three weeks back and no thrill in the fistula. No other features of hyper coagulability. Now on temporary jugular Cath, and not willing for CAPD.
What would be the other options for long term access apart from tunnelled catheter. We are considering a leg fistula between posterior tibial and great saphenous. Any suggestions or experience with lower limb fistulas?

---------------------------------
Varun Kumar Bandi
Assistant Professor,
Department of Nephrology,
Dr. PSIMS & RF
Vijayawada, India
varun.vims@gmail.com

Original post:

One of the large dialysis organizations measures dynamic venous pressure, rather than static venous pressure, as their sole AVF and AVG surveillance metric.

Please comment on whether you find this useful or reliable.

You must have an approved log-in on ASN Blog site to see post and comment -  

https://community.asn-online.org/communities

https://sites.google.com/site/abigailsarticles/december-2021-articles

This Week – Bleeding Catheter

We want to engage with each of our members - feel free to comment below.

ASDIN TV recently held a Catheter Roundtable discussion.  Each Monday through August 9th, we will release a new portion of the roundtable discussion. 

This Week – Catheter Infection

We want to engage with each of our members - feel free to comment below.

ASDIN TV recently held a Catheter Roundtable discussion.  Each Monday through August 9th, we will release a new portion of the roundtable discussion. 

This Week – Stuck Catheters.  

We want to engage with each of our members - feel free to comment below.

We want to engage with each of our members - feel free to comment below.

Thanks

Varshi

I am a solo interventional nephrologist in Seattle and am looking for part time/locums coverage.  Could become a full time position if I find the right candidate.  Also willing to work with locums type provider.  Does anyone have experience using a locums firm?  Any names/leads would be appreciated (information regarding good/bad experiences would be appreciated.)  I looked on the job board here and it does not seem very active re: interventional nephrology.  I'd consider IR or vascular surgeon if they have extensive HD access experience.

Thanks,

Peter Gregory

In furtherance of our mission, ASDIN values diversity, inclusion, tolerance, respect for others, and, above all, the value of human life. The American Society of Diagnostic and Interventional Nephrology vows to continue to raise a collective voice against injustice.

Statement by Executive Committee - Anil Agarwal, MD;  Vandana Dua Niyyar, MD;   Bharat Sachdeva, MD and Monnie Wasse, MD - on behalf of ASDIN

In an effort to support patients who may be indirectly affected by COVID-19, Medtronic recently announced a donation program for the IN.PACT™ AV Drug Coated Balloon for Arteriovenous Access Maintenance in patients with end stage renal disease (ESRD). ESRD patients undergoing regular hemodialysis, which has been deemed an essential procedure during the pandemic, are at high risk for exposure to and complications from COVID-19.

In the IN.PACT AV Access Trial, IN.PACT AV demonstrated a 56% reduction in fistula reinterventions vs. PTA at six months1, offering a unique clinical benefit. Medtronic hopes this donation program will help extend the time to reintervention, thereby limiting the time ESRD patients are in the hospital.

U.S. sites affected by COVID-19 and performing AV access maintenance procedures may submit IN.PACT AV product donation requests via theMedtronic Giving Connection. Medtronic will donate up to $10 million in product, with each request fulfilled using a standardized 10-unit kit.

1.Results from the IN.PACT™ AV Access Clinical Trial found in the IN.PACT™ AV drug-coated balloon (DCB) Instructions For Use (IFU).

More Information:https://www.asdin.org/resource/resmgr/covid_19/INPACT_AV_Donation_Applicati.pdf

Apropos discussion of elective vs urgent/emergent cases. – Our program does on average 9-10 cases per day, 1-2 thrombectomies, 2-4 fistulograms with angioplasty that were on the verge of thrombosis, 1-2 tunneled catheter procedures, and the rest more or less elective stuff (not so urgent fistulogram stenoses, central vein recanalization, hand pain [depending on degree of pain may be urgent], etc.).

Our concern has been that we cannot distinguish without patient contact which of the fistulogram referrals are urgent/emergent versus relatively elective. We find that if a dialysis unit thinks there is a problem there usually is a very advanced problem and we know that we cannot deal with 5-6 thrombectomies every day.

For this reason we have made almost all referral indications “high priority” (see pasted below), similary for OR procedures. – We also have access to two procedure rooms and designated one of the rooms a Covid-19-+ve space to brings patients directly into the room, improve staff/provider adherence with PPE policies, and facilitate room cleaning/air exchange [the latter is an overkill policy by hospital that will likely fall by the wayside, it holds true for TB/airborne, but should not apply to Corono/droplet]. – Lastly, all consents are done verbally.

The experience in Asian and Europe suggest a 40-50 days curve without flattening and something (much) longer with flattening. So our question is “Can this access problem wait for 3 months or not?”. Most interventions buy at least 3 months time, so anything we can do now prevents an emergency procedure during a period when everybody is sick, staff is out, providers are cross-covering.

Baseline assumptions:

1. There will be more Covid19 exposed / infected (:= Covid19+) dialysis patients than hospitals can manage to dialyze as inpatients (so admitting all of these patients is unlikely to be a solution)
2. Consequently, some Covid19+ dialysis patients will dialyze in the community, possibly dedicated HD units, and will look for dialysis access care in the usual way
3. There will be a subset of Covid19+ dialysis patients who will require dialysis at hospital after an emergency access procedure due to volume/hyperkalemia/scheduling issues, 20-33% of thrombectomy patients seems a reasonable estimate
4. We will not decline care for Covid19+ patients
5. Care may return to “normal” in 3 months (40-50 days for rise and fall of cases with a tail)

Process of care questions:

1. Is there a way to create/dedicate “isolated” pre-post-evaluation/monitoring space? 
2. What are room cleaning and air exchange requirements after a Covid19+ case?
3. Can procedural space be dedicated to Covid19+ patients?
4. Timing of Covid19+ cases during the day to allow for cleaning procedure if dedicated space limited?
5. Where will Covid19+ outpatients receive emergency post-procedure dialysis ?
6. How is EMS and The Ride handling Covid19+ patients?
7. Will the waiting room be able to accommodate Covid19+ patients in a safe way? If not, what space is available for Covid19+ patients to wait?

Triage Process for Dialysis Access procedures - Endovascular

High Priority (access := fistula/graft/PD catheter/tunneled hemodialysis catheter that are used for dialysis):

1. Outpatient thrombectomies without other access
2. Outpatient bleeding access
3. Outpatient access with clinical/laboratory signs of extreme dysfunction or inability to use
4. Outpatient access with signs and symptoms of cardiac strain, limb ischemia and impending tissue loss (high flow)
5. New initiations with volume or electrolyte emergencies/urgencies
6. AKI in ICU/floor with need for dialysis
7. Outpatient access with new onset arm edema jeopardizing use of access or incapacitating limb use/movement
8. Inpatients thrombectomies
9. Inpatients access dysfunction (may not be as extreme as above) if this keeps patient in hospital
10. Outpatient access, not in use, with impending signs of occlusion
11. Catheter removals (as long as staff and resources available, to prevent infections during time when staff and resources are overwhelmed)
12. Venograms for access creation on specific urging of nephrologist when surgery is also pressing ahead (See Open Surgery HD Access Cases Performance Plan)

Low Priority:

1. Venograms for access placement (occasionally they may be necessary to guide urgent/emergent revision of a dysfunction/non-functional access)
2. Scheduled follow-up exams – institute enhanced screening by phone asking specific data on access function: trend of access flow past 4-6 months, trend of clearance 4-6 months, change in bleeding after needle removal, obtain photo of access  

Open HD Access Cases Performance Plan

Joint HD access clinics will continue with individual visit review the week prior for appropriateness and opportunity for delay/virtual or phone visit

Delay these types of cases:

• New HD access placement in stable, minimally to asymptomatic patients with eGFR of >15
• Permanent HD access placement in patient with functioning catheters and no known issues with catheter infections, thrombotic complications
• Asymptomatic non-used fistula ligation
• Asymptomatic AV access aneurysms without threatening signs (large thrombus, thin skin, etc.)
• Difficult augmentation/cannulation in patient without ESRD

Continue with example cases below:

• Thrombosed/failing access unable to be managed by endovascular approach
• Steal syndrome
• High flow access with complications such as Bleeding, CHF, Steal
• Infection
• Difficult augmentation/cannulation in patient with catheter in place
• Failure to mature with impending access loss
• Procedures requested for expedited care by referring nephrologist
• Inpatients in which access procedure will expedite patient progression
• Tunneled hemodialysis catheter placement or exchange that otherwise cannot be accommodated

To be reviewed real time for iterative as needed modifications

Here, I have images of a graft placed in April 2018, and replaced with a Flixene graft (no catheter) this month, lasting less than 2 years. Ironically, her first graft was a Flixene, placed in 2012, and replaced in 2018 with the Acuseal. I took segments out during this last transition because I wanted to know why the Acuseal did not last as long as the Flixene. In one image, fibrosis in the zone of frequent cannulation pushes a partly disrupted silicone layer further into the lumen. In the other, the graft wall is fairly well preserved, but the lumen is full of an amorphous hyaline material, also present in the other image. I don't see many sectioned dialysis grafts, but I have never seen this kind of hyaline material in a newer graft, and especially not where the graft has not experienced heavy use. Remember that these graft segments were running and not thrombosed when they were excised and replaced. Any ideas? I will be reviewing this with a pathologist this week, and may have better images then. The specimens have been preserved if there is an interest.

I will be doing a retrospective review of the Acuseal versus the Flixene, perhaps with a standard PTFE, and a BVT group as well.

Here, I have images of a graft placed in April 2018, and replaced with a Flixene graft (no catheter) this month, lasting less than 2 years. Ironically, her first graft was a Flixene, placed in 2012, and replaced in 2018 with the Acuseal. I took segments out during this last transition because I wanted to know why the Acuseal did not last as long as the Flixene. In one image, fibrosis in the zone of frequent cannulation pushes a partly disrupted silicone layer further into the lumen. In the other, the graft wall is fairly well preserved, but the lumen is full of an amorphous hyaline material, also present in the other image. I don't see many sectioned dialysis grafts, but I have never seen this kind of hyaline material in a newer graft, and especially not where the graft has not experienced heavy use. Remember that these graft segments were running and not thrombosed when they were excised and replaced. Any ideas? I will be reviewing this with a pathologist this week, and may have better images then. The specimens have been preserved if there is an interest.

I will be doing a retrospective review of the Acuseal versus the Flixene, perhaps with a standard PTFE, and a BVT group as well.

Here, I have images of a graft placed in April 2018, and replaced with a Flixene graft (no catheter) this month, lasting less than 2 years. Ironically, her first graft was a Flixene, placed in 2012, and replaced in 2018 with the Acuseal. I took segments out during this last transition because I wanted to know why the Acuseal did not last as long as the Flixene. In one image, fibrosis in the zone of frequent cannulation pushes a partly disrupted silicone layer further into the lumen. In the other, the graft wall is fairly well preserved, but the lumen is full of an amorphous hyaline material, also present in the other image. I don't see many sectioned dialysis grafts, but I have never seen this kind of hyaline material in a newer graft, and especially not where the graft has not experienced heavy use. Remember that these graft segments were running and not thrombosed when they were excised and replaced. Any ideas? I will be reviewing this with a pathologist this week, and may have better images then. The specimens have been preserved if there is an interest.

I will be doing a retrospective review of the Acuseal versus the Flixene, perhaps with a standard PTFE, and a BVT group as well.

Has anyone else had these problems with Acuseal grafts? Are there any insights to share?

"We are still not getting paid when we bill the 36595 with modifier 52.  I called Medicare again today to clarify and the code is being bundled with the  36581.  The only way to un-bundle this would be with a modifier.  I am not sure if there is an appropriate modifier to use in these cases as the 36595 is being done at the same site as the 36581.  Any guidance you could give me on this would be appreciated.  Thank you!"

I offered to share it here to see if anyone has had any luck getting this code paid, what modifiers they are using, etc.  We do use the coding manual tip of adding an additional statement to our procedure note.

Any info would be appreciated, thanks!

At 4:45PM EST today on 7/11/2019 the detailed proposal was released for public inspection at https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-14902.pdf. The proposed rules are 413 pages. Ironically, the authority for the regulation comes from the Obamacare Law that the Administration supports eliminating.

Here is the experiment being proposed: The USA will be divided into 306 groups of zip codes called Hospital Referral Regions.  153 Hospital Referral Regions will be randomized to provide incentives for nephrologists to refer for home dialysis (mainly peritoneal dialysis) and transplantation and 153 regions will be randomized to the status quo.  The providers whose payments will be affected by the randomization will be the dialysis unit and the nephrologist.  Since this is a legislative experiment rather than a clinical trial the requirement for informed consent will be waived; rather, participation will be mandatory for the providers. It is called the ESRD Treatment Choices Model (ETC Model).

When the study is concluded in 2026, the data can be analyzed to determine whether the clinical and financial outcomes are better with the payment incentives and whether the administration’s goal of increasing home dialysis and transplantation through the incentive program is being achieved. Then the incentives could be implemented systemwide.

As we well know, in recent years, CMS has been trying to reduce ESRD expenditures by reducing the payment rates for the services are were needed to maintain hemodialysis access and has run into increasingly loud resistance from providers (like myself)  that performed those services and who had an opposing concentrated interest. This policy does an end-run around the HD maintenance payment conflict by incentivizing home dialysis (mainly peritoneal dialysis) and transplantation which all virtually all specialists agree is much cheaper to maintain. 

That home dialysis and transplantation are less costly than in-center hemodialysis there is no doubt. Whether the clinical outcomes of home dialysis are better than the clinical outcomes of in-center dialysis are presently uncertain. In my opinion the data currently available suggests clinical outcomes are about the same.  CMS proposes to resolve this uncertainty by structuring the payment reform measures as a massive nationwide prospective randomized non-blinded study that will study the effect of home dialysis/transplant payment incentives on cost and outcomes.

It is obvious that the costs of ESRD care have grown so high that something must be done or the Medicare system will be bankrupted.  But America doesn’t need a grand social experiment to decide whether to  incentivize less costly home dialysis and transplantation.  The administration has the legal authority under the Obamacare Act to implement the proposed innovation systemwide without limiting them to  randomly chosen geographic areas.  I would urge that the regulations be revised before the final rule is issued making the incentives applicable throughout the America, while it monitors clinical and financial outcomes.  Ultimately, the Secretary of HHS has the authority to stop the study  program as soon as it is clear that money is being saved without adversely affecting clinical outcomes and make the changes permanent. I hope this is done as soon as possible.

Sincerely,

Eric

Eric Ladenheim MD

LDAC Vascular Centers

The patient complained of dyspnea and chest x-ray showed cardiomegaly.

Vascular ultrasound was performed on suspicion of vascular access thrombosis.

Radiocephalic fistula had no thrill.

The attached image is an ultrasound examination performed at admission.

The ultrasound waveform is thought to be somewhat different from that of general thrombosis.

In conclusion, the patient underwent pericardiocentesis as an emergency after diagnosis with

acute cardiac tamponade.

I wonder if the shape of the ultrasonic waveform of the attached file is related to the cardiac

tamponade.

Thank you.

The manufacturing changed to Mexico and there appears to be something happening.

And of course would want to make sure that anyone seeing a product defect should report the device failure to the manufacturer.  And please report additional catheters that have the same problem.  

Would love to hear if others are seeing this.

Does anyone know if there are any hand-held US devices which can measure flow?  Thanks.

Thank You

Link to the National Kidney Foundation website- go to the Guidelines tab and then at the bottom of the page you can register to be a reviewer when the public review is active!  Please sign-up as these guidelines will impact your local Process of Care!!!

A social worker posted on the CNSW listserv that her patient had a clotted access that has caused a lot of pain over the last few years, so we are cross-posting here. Patient now has a CVC and is getting a fistula in her other arm. The patient has swelling and pain in the arm where the fistula is clotted and has told the Social Worker that when the CVC is used it feels like her veins are being pulled out. Her surgeon has told her there isn’t a surgical option to resolve the pain she is feeling. Hate to hear of a patient having pain during each dialysis treatment.   Asking for ideas to see if you have tips or suggestions.

They would like to know what policies other centers have in place in regards to a responsible person staying in the waiting room for the duration of the patients procedure. We would like to implement this, but there are a few variables. Some patients do not have anyone and rely on share a fare or other transportation options, some have someone to drop them off, and return after procedure. 

We had the Privilege to perform our first three endovascular AVF's using the wavelinQ system early this week.

All were an immediate technical success. We will follow the patients closely to the time of cannulation. 

I am very grateful to my team at the VAC and the patients that put their trust on us.

Here are the most meaningful images of our very first patient - these include a the final run and blood flow volume by me two days later

The second video is the final run of the second patient. 

The third is a still corresponding to the final patient.

Now we will follow them until the are ready to be accessed

Thanks,

Alejandro Alvarez

SSM VAC STL MO

What are your methods for achieving hemostasis post sheath removal?    I use  a nylon suture and  I  write an order for  my hemostasis suture be removed at the next hemodialysis session.   It also serves as a reminder to the dialysis unit that this patient had something done to their access; maybe we should read the procedure note and find out if we should do something different.

One of the LDOs has adopted a policy that only allows MDs and Advanced Practitioners to remove sutures in their dialysis units.  Nurses and techs have a long history of removing sutures competently. Apparently it is a liability issue.

Manual compression works but is labor intensive and takes  time which is not an efficient method in a busy access center with rapid turnover.   I can remember a few patients who came back to the access center who started bleeding in the car ride home.      I suppose leaving the sutures for one or two weeks until the rounding MD or AP can remove the suture in the dialysis unit is safe but that  does not seem ideal. Does anyone use absorbable sutures  or skin glue?    

Jeff Hoggard

ASDIN Members - We have received an inquiry from a CRNA on grafts clotting during surgery..  Please assist by responding to this post.

From Michael-Malachi Cohen CRNA, MSN

We have had at least 3 Dialysis grafts fail during surgery.  The cases were at least 4 hours each and with the patient in Trendelenburg positioning.  None of the cases involved direct pressure on the graft sites.  If possible please supply any information, algorithm, or standard of care that you have available on intraoperative monitoring of these access sites. 

Thank you for your time and effort as you look into this for our facility. 

Malachi

Hi all;

Our institution is looking into upgrading our current retiring C arm.

Has anybody upgraded such equipment in recent years ? any advice ?

https://sites.google.com/site/abigailsarticles/september-2018-articles_1

I would like to know what is the consensus on using clamps for hemostasis post dialysis cannulation:

1) No clamps. Only manual compression after removal of the dialysis needles

2) One clamp at a time

3) remove both needles and use two clamps

4) use clamps for fistula but no clamps for AVG 

Thanks,

For CPT codes 36902 and 36905, quality measures listed for MIPS are:

measures   FLUORO recorded with dose: 145

                    Venous Thromboembolism Prophylaxis:  23

                    Antibiotic Prophylaxis:   21

                     Calculation of surg risk:  358

Measures 23 and 21 seem irrelevant for 36902 and 36905.  If you use these measures for these cases, you will check off "exempt" for each case you don't use prophylaxis.  You can get points for this, but in order to score a full number of points, you have to do at least 20 cases of prophylaxis for each measure.  Is anyone actually doing this?  Does anyone know why these measures are even linked to these CPT codes?  We have been in touch with CMS and they are silent on "why".  They simply state how they are used and how they score.

I routinely use 145 and 358.  But I need he other two measures to achieve compliance with the number of required measures.

Thoughts?

Thanks,

GMGaylord MD FSIR

As some of you may know, CMS now requires High Level Disinfection (HLD)for all Medicare deemed ASC.

Failure to meet this requirement is considered a condition level deficiency.

In the context of Vascular Centers, this means HLD of ultrasound probes.

Only practical solution we have come up with is to consider Trophon since use of glutaraldehyde is impractical in our setting.

However, Trophon's list of compatible ultrasound probes is limited and may not include for example MindRay which is what we use at our Center.

I wonder if any one else is faced with similar challenge and what they're doing about it. Thank you in advance for your feedback.

Naveen Atray

Sacramento, CA

Wanted to check in with members of the ASDIN community regarding the use of trialysis catheters in the hospital. Does anyone have specific policies/procedures regarding indications for placement and maintenance of these catheters? They are convenient in those patients in whom access sites are limited, but are there potential downsides to their use?

1. Are there any reports of increased infections, given that the third lumen is typically accessed for central venous access/infusions?

2. Any flow concerns? Though they are typically the same in diameter as temporary HD catheters (12-14 Fr), given that  there are now three ports instead of two, the individual diameters of each would be decreased, and may hypothetically result in flow limitations.

3. Any recommendations for routine care/maintenance including saline/heparin locks?

Thanks in advance for your input. 

afraid to pull out with fogarty placed on Eliquist instead 

surgeon notified

comments please

In an effort to make things a little less serious...

 I wanted to ask fellow interventionalists if they play music in the procedure room and if so, what are their preferences/dislikes. Are is there particular music you play depending on the type of procedure?

in our Fluoroscopy suite we typically have the radio on to a station that typically play's 80's music, which I like, and many of the patients seem to be able to relate to and enjoy.

Best Regards R Kris Ellis MD FASN, FASDIN

Wondering if the MD has to be present at the facility when the procedure is being performed, like a dialysis visit in the hospital when the pt is on the machine.

I’ve seen other units use PA’s in this fashion with the PA being the person completing the entire procedure but there is always an MD on the premises.

Lastly, if the procedure can be billed under the PA do you only get 80% from CMS?

Thanks in advance.

My 10-year old Phillips BV Pulsera is wearing out and I am shopping for a new machine. I am looking at the Phillips Veradius Unity and the GE OEC Elite CFD (not the 9900 version). Does anyone have experience with either machine?

Thanks!

Direct email to mnations@asdin.org if you are willing to connect.

Are there any information about the fact that CMS may pay FGM and access related procedures at EOP rates even if an access center went through the ASC certification? and what, as a Society are we planning to do about it?

thanks

I have looked online for emergency consent guidelines however most deal with blood transfusions, minors and don't relate to our situation.  I have found this verbage on several documents:

An emergency must meet all of the following criteria:

a) The patient's life or health must be in immediate and substantial danger.

b) The patient is incapable of consenting.

c) Any potential risks associated with the treatment are materially outweighed by the

potential benefits associated with treatment.

So my question is what do you do in these situations? 

How many signatures do you require on your consent forms if any?

Do you have any P&P's you would be willing to share?

Thank you in advance for your help,

Nicole Davis

I will share summary report on blog.

Here is a preview of the survey questions below:

1) Do you routinely suture the entry site of access after intervention. Yes no

2) if so what is the material used a)proline b ethilon

3) when do you take it out a) waiting room b) next day

4) do dialysis units take them out for you. Yes  no 

         This patient with ESRD had a left brachiocephalic vein stenosis (CTO) with upper limb edema ( there was no access on that side then). We did an angioplasty and stenting 8 months ago with complete resolution of edema. He was getting dialysis through a right sided jugular tunnelled catheter. Now that we wanted to create a permanent access for him ,went ahead and did a left brachio axillary graft. He developed arm and forearm swelling after that which is persisting and increasing. There was no sign of cellulitis. It has been a month now since creation of the graft and the swelling is still there and we have not used the graft yet .We did a venogram through the graft which looks normal without ant central stenosis/instent stenosis.I have attached the images of the graft vein junction, the central outflow and a short video of flow through the graft vein junction. What could be the reason for the swelling? How to proceed next? Inputs please...

Thanks

Dr Venkatesh,

Chennai,India.

REMINDER:  Deadline for ASDIN's Call for Abstracts for 14th Annual Scientific Meeting is 10/31/2017

- Any data, guidelines or policies adopted by anyone regarding routine exchanges of TDC without an indication to prevent catheter getting stuck in central vessels/right atrium or wear of the catheter.

Over the years I've come across several instances of steal, with significant forearm artery disease.  With high flow fistulae, usually we have reasonable results with banding.

The more challenging cases seem to be the lower flow fistulae, especially those with calcified forearm arteries.  We usually refer these for a DRIL/ proximalization of arterial inflow. 

The patient here presented with an ulceration at his 5^th finger, consistent with distribution of flow from the ulnar artery.  Here, it appeared that the culprit was steal with the presence of a calcified ulnar artery.

I generally approach these cases with a full arteriogram, and address any clear, focal lesions with angioplasty.  However, I have been somewhat reluctant to pursue diffuse arterial calcification – with concerns for spasm/ trauma with angioplasty of extremely small vessels. 

Just wanted to see what some of your experiences are with these type of small arterial vessel issues.  Is anyone using arthrectomy on these types of cases?  Do any of you stent these lesions or pursue attempts at angioplasty with diffuse vascular disease?

Forearm arterial calcification seems similar to lower extremity peripheral arterial disease –and there have been significant advances with endovascular arterial arthrectomy and treatment of limb ischemia.  Are any of you employing these techniques in forearm arteries?

Danny Patel

[ 7/10/2017:  ADDED IMAGES FROM DR. POURCHEZ]

In regard to the Coding Alert from 12/27/16 on moderate sedation claims, can you tell me if this has been corrected and if I should go ahead and rebill or appeal these sedation codes? I called Medicare today (4/12) and they didn’t seem to know anything about this. 

A:  The new NCCI procedure to procedure edits did come out April 1 so it makes sense to resubmit claims, though carriers sometimes lag behind. Apparently, some intermediaries have been able to make corrections internally and are paying the codes for sedations.  Other intermediaries are not able to make the corrections internally and are having to wait until Medicare makes them.   For this reason, some are now paying and some are not.  Probably will be some variability in local carriers for a while.

I had had an interesting PD case today that I thought I would share, as this is the 

first time I have seen this.

I was sent a patient with a laparoscopically placed right sided double cuffed

coilec PD  cather with midline infra-umbilical approach about 5 weeks prior with

intra-Peritoneal fixation. He was sent for complete outflow failure and 

inflow with some resistance.

We initially flushed and aspirated a few fibrin plugs from the 

catheter - we did not manipulate the PD catheter with wire or 

styler. On PD gram I see what I think is encasemrnt of the coil

and I think separation of the catheter with injection. (Video link included)

my suspicion is that the catheter might have torn perhaps by 

coming in contact with the staples then completly separated on 

contact injection.

the pt will see the surgeon for Laparoendoscopic replacement.

i am interested in knowing if others have seen this and their thoughts.

Raj.

Now i don't know if

     a) I have to remove the catheter or to keep it insitu

     b) Convert this temporary line to a tunnelled line ( with a possible risk of embolization during the procedure)

     c) Create an AVF ( with a possible risk of immaturity/failure secondary to a compromised central vasculature)

I don't know how much of my fears are real..expecting inputs from the experts..

 Please use the youtube link above for the video.

Dr Venkatesh Rajkumar,

Chennai,

India.

My question is whether anticoagulation is required or appropriate in this setting? Would you use Lovenox and/or Warfarin? For how long?

Thanks,

Tim Pflederer

An issue I've come across a few times but honestly have only relied on standard and drug-coated balloons for my intervention has been the refractory anastomotic stenoses at a terminal artery.  By this, I mean either a Radial-Cephalic AVF where the Radial Artery distal to the AVF is completely occluded (and thus all flow to the hand is via the Ulnar Artery, with the Radial Artery essentially merely supporting flow to the AVF itself), or in an upper arm AVF where the surgeon inadvertently vs intentionally used a High-Takeoff Radial Artery for the inflow and again the artery distal to the anastomosis becomes quite atretic, thereby leaving the Brachial/Ulnar to supply the forearm/hand.  I have not seen lasting (and honestly nor did I expect) results from either standard/DCB's of the arterial anastomosis.

Today was another such example.  Aside from sending the patient back to surgery to move the arterial anastomosis more proximal, have any of you simply stented this region into the artery itself since the atretic segment of the artery distal to the anastomosis is essentially non-functional anyway (provided you have first documented adequate flow to the Palmar Arch via another vessel)?

As you can see from the (soon to be uploaded) picture, I'd hate to lose such an otherwise nice AVF during a proximalization of the arterial anastomosis.  However, we're also talking about already small vessels here, so would a 5mm Viabahn vs other stent actually provide enough increased vascular lumen to make a difference?

Regards,

Kevin Harned, MD

The letter states our use of 37241 does not reflect vascular embolization or occlusion as defined by AMA (congenital or acquired venous malformations, varices, varicocele, venous/capillary hemangiomas).

I wonder if anyone else is in receipt of this letter. The use of this code seems perfectly in line with RPA/ASDIN Coding manual. I would be curious as to  how ASDIN coding committee would respond to it? 

Thanks.

Naveen Atray 

Sacramento, CA