Saudi Journal of Kidney Diseases and Transplantation

LETTER TO THE EDITOR
Year
: 2013  |  Volume : 24  |  Issue : 6  |  Page : 1250--1251

Dialysis access technology, the next generation


Alan S Coulson 
 Sandhills Regional Medical Center, 108 Endo Lane, Suite 1, Hamlet, NC 28345, USA

Correspondence Address:
Alan S Coulson
Sandhills Regional Medical Center, 108 Endo Lane, Suite 1, Hamlet, NC 28345
USA




How to cite this article:
Coulson AS. Dialysis access technology, the next generation.Saudi J Kidney Dis Transpl 2013;24:1250-1251


How to cite this URL:
Coulson AS. Dialysis access technology, the next generation. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2021 Jun 24 ];24:1250-1251
Available from: https://www.sjkdt.org/text.asp?2013/24/6/1250/121293


Full Text

To the Editor,

In the past, the development of neointimal hyperplasia resulted in progressive scarring and eventual obstruction at the venous anastomosis of a hemodialysis access graft. Revision surgery and angioplasty have incurred enormous costs to Medicare. In 1999, a change in the geometry of the graft-vein connection, namely the endovascular insertion of the venous end of the graft inside the vein, circumvented many of the contributory factors causing neo-intimal hyperplasia. [1]

Now, it is time to reconsider the actual material used in the construction of the venous end of the dialysis graft. By virtue of its ability to induce tissue ingrowth and bonding and thus tolerate repeated needle sticks, Polytetrafluoroethylene (PTFE) is a suitable material for the body of the graft. But, in turn, this very same quality probably means that PTFE is not the optimal material to interface with the actual wall of the vein as it probably contributes to the induction of neointimal hyperplasia. This calls for two different materials in the final assembly of the hemodialysis access, one for the body and another for the venous end, such as employed in the constriction of the HeRO graft (Hemosphere, Eden Prairie, MN, USA), which works well in the central venous system. For decades, silastic and other similar materials have been used in veins, subject to the same physical stimuli as dialysis grafts but without the development of neointimal hyperplasia.

This new generation of hemodialysis technology could now be extended to the peripheral venous system by exploiting technology that already exists in the field of heart surgery. Access to the arm veins could be accomplished by using pediatric venous cannulae, naturally with the direction of flow reversed, (DLP malleable single-stage venous cannula, Medtronic, Minneapolis, MN, USA). The range of sizes means that this cannula could be used in different-sized veins. Another big attraction is the malleability, meaning it can be adjusted to the anatomy of the patient and, better yet, it can be molded into a "lazy-S" configuration, like a freeway on ramp, to avoid sharp bends. The universal connector could be used to join the cannula to the body of the graft.

Two simple additions would be required, again using technology already available in the realm of the heart surgery. The first would be the gluing of an oval tricuspid valve annulus sewing ring (Edwards, Irvine, CA, USA) to secure the venous insertion [Figure 1]. The second would be the attachment of tines on the exterior of the tip of the venous insertion to keep it from touching the endothelium; these would be similar to the tines used on pacemaker leads.{Figure 1}

Avoiding contact between PTFE and the vein is the next generation of dialysis access technology.

References

1Coulson AS, Quarnstrom J, Moshirnia J. A combination of the elephant trunk anastomosis technique and vascular clips for dialysis grafts. Surgical Rounds 1999; 22:596-608.