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I M P O RTA N C E O F TI M E WHEN IT BECOMES obvious that patients need long-term dialysis, the process of constructing arteriovenous (AV) grafts or fistulas needs to start immediately because maturation and the ability to utilize the access may take several months, according to Melissa D. Shah, MD, vascular surgeon at Vassar Brothers Medical Center. "The sooner patients are referred for long- term dialysis access, the better," she says. "Many don't realize how long the process takes. Catheters are great because we can use them immediately, but our goal for chronic kidney disease patients is to avoid catheter-based dialysis entirely so we can avoid its associated complications." If AV grafts are required because the veins are too small, the process should begin no later than two weeks before dialysis, Dr. Shah notes. This allows the graft to heal and incorporate under the skin. Following this phase, it takes dialysis centers two weeks to transition from catheter-based access to the graft. AV grafts are more quickly accessed than AV fistulas because they don't require as much time to heal. For AV fistulas, it typically takes at least eight weeks for the superficial vein to grow, to strengthen and to accom- modate high-volume blood flow. completely asymptomatic, and because outward signifiers are absent, Dr. Shah recommends that after PAD diagnosis, these patients be tested for concurrent heart disease. PAD can lead to serious complications that can compromise limbs. If arterial claudication is not caught early, patients can develop ulcers and even gangrene in their toes and feet. To identify the disease before it endan- gers limbs, Vassar Brothers' vascular surgeons employ a number of in-office, noninvasive testing methods, including pulse volume recording (PVR), as well as Doppler and ultrasound imaging. PVR measures volume changes in differ- ent parts of the body, and vascular surgeons use these measurements to identify clots or blockages in extremities. Doppler and ultrasound imaging confirms the presence of a blockage by visualizing the artery with sound waves and measuring blood flow. When these tests evidence blockages, Dr. Shah schedules a diagnostic angiogram. During the angiogram, vascular surgeons often attempt to revascularize the blocked artery using various minimally invasive techniques, including angioplasty, stent placement and atherectomy. Dr. Shah explains that by use of a needle stick in the groin, a catheter is inserted and guided to the blockage. Then, a small balloon attached to the catheter is inflated to hold the artery open. If necessary, a stent is placed to ensure the artery remains open. Open surgical revascularization includes hybrid procedures, prosthetic bypasses, in situ bypasses (using the long vein running down the length of the leg), or free vein bypasses using any combination of veins for the legs and the arms if needed. Sometimes the angiogram reveals that endovascular revascularization will not be the most effective treatment. "During angiography, we're able to classify blockages of different severities at different levels in the anatomy," Dr. Shah explains. "We then compare our findings PHOTOS © DON DEMPSEY, WHITE LIGHT PHOTOGRAPHY Dr. Saltzberg reviews diagnostic images to formulate the optimal treatment plan. Jeanette Jackson, RT(R), Special Procedure Technologist, assists Dr. Spirig with an interventional procedure. M D N E W S . CO M ■ MD NEWS Mid Hudson | 7