My name is Alayne Gagen, I’m the Renal Vascular Access Nurse specialist for CMFT, or VANS for short, many of you will know me from both the transplant unit where I started my renal nursing career in 1983 until 1999 and then on the haemodialysis unit till 2014 when I was offered my present role. This role came about through the BKPA (now known as Kidney Care UK) and was funded for 3 years, becoming successfully substantive in 2015. My passion is access and the surveillance and care of it, as this is a patient’s lifeline and should be respected as such. I have recently been appointed the co-chair of the British Renal Society Vascular Access Special interest group, along with also being an involved member of VASBI (Vascular Access Society for Britain and Ireland). I also cover all the satellite units within the conurbation of CMFT so do go out to Macclesfield, Stockport, Altrincham, Tameside and North Manchester. I work very closely with the surgeons, interventional radiologists, vascular scientists, nephrologists, nursing staff and patients in order to try and improve our service. I am currently in the midst of doing road shows at each of the dialysis units to raise awareness about the importance of good access, to meet with patients and talk to them about the benefits as well as provide an educational aspect for nursing staff, which will and has done so far highlighted further training needs and interest.
Lots of work has been done around what is the best choice and most appropriate access for dialysis, there is a lot of evidence to say that an Arteriovenous Fistula (AVF) is the gold standard, as a result, the Renal Association wanted every dialysis unit to work towards having at least 85% of their prevalent patients (patients on dialysis for above 91 days) on an AVF and 60% of their incident patients (patients that have been dialysing for less than 90 days) to start with an AVF. This figure has now been reduced recently to 80% in the prevalent population and proving difficult to achieve for most units due to the many variables that affect successful vascular access.
CMFT realised that in order to get to this figure there needed to be a more streamlined service with someone overseeing this, hence this role being developed. The aim of the role being to ensure a timely referral to the surgeons, to attempt to meet the guideline percentages, oversee clinic and theatre attendances as well as ensure that educational needs of nursing staff are met with new developments being introduced in order to ensure an improved patient experience as well as meeting national targets for CMFT.
Renal vascular access proves to be one of the most challenging aspects of renal care, especially trying to decipher when it is necessary to ensure that access is available for the start of dialysis. There are 4 types of access available to patients, the gold standard being an Arteriovenous Fistula (AVF), which is created from a patient’s own vein and artery during a small operation under local anaesthetic generally. The others are an Arteriovenous graft (AVG) using synthetic tubing which is tunnelled under the skin, Central Venous Catheter (CVC), which is a tunnelled synthetic tubing positioned in the chest under the skin, HeRo, which is a hybrid between a CVC and AVG, so like a tunnelled line but with a piece of synthetic tubing attached, tunnelled under the skin. All of which have their advantages and disadvantages.
The overall benefits of having an AVF are that it uses a patient’s own native vein and artery and provides a good blood flow for dialysis, which increases the effectiveness of treatment, thereby improving the patient’s health and well-being allowing them to live a better life and carry on with work. The risks of clotting and infection are significantly lower than those of other access, thereby reducing the number of admissions and antibiotic therapy patients have to undergo. AVFs are normally created as an outpatient under local anaesthetic and can last many years if cared for correctly.
The process of having an AVF created is as follows:
- All patients are counselled as to what treatment is available to them, if haemodialysis is chosen then access is discussed.
- The patient is then referred to the surgeons for a consultation; this generally takes around 4-6 weeks for a clinic appointment, this is called a ‘one stop’ clinic.
- The consultation with the surgeon takes place after having a vein map (ultrasound mapping of vessels to see if they are suitable for an AVF), all done within the same appointment. The decision whether to go ahead will be made within that appointment, and the patient will then be added to the waiting list for theatre, this can take up to 3-4 weeks, longer if a general anaesthetic (GA) is required due to the need to be seen pre-operatively and assessed as suitable for a GA.
- The patient attends the Elective Treatment Centre, where they will have their blood pressure and other vital signs taken as well as bloods. They’ll be seen by the surgeon to consent for the operation, which generally takes around 30-45 minutes under a local anaesthetic (LA)
- Once the surgeon is happy that the patient has recovered sufficiently to go home the patient will be discharged, generally 4-6 hours after the AVF creation. The patient is advised to check the wound site daily, check for the thrill (feels like a buzzing sensation under the skin) and commence exercises after 10 days, driving is not permissible until after 2 weeks.
- A follow-up appointment will be sent for between 6-8 weeks after the operation, where, once again, an ultrasound scan will be done but looking at the depth, diameter and flow of blood in the AVF to determine whether it can be used for dialysis purposes, more commonly known as maturation. The surgeon will, at that point, decide whether this can be cannulated or not (needled), and the nursing staff will be informed accordingly.
I’m more than willing to discuss any queries around access, and my telephone number is 0161 276 7985.
Alayne Gagen
