Five local doctors were recently featured in an international medical journal for performing a new technique which will benefit hundreds of patients undergoing dialysis treatment for renal failure.
With 1,000 dialysis patients in the country, one of the main problems is the creation of an access point in the body to hook up the dialysis machine.
Surgeons Dale Maharaj, Michael Ramdass, Adedapo Oladiran, Riad Baksh and Emerson Budhoo were able to perform a technique which created an access point in a new site on the hand. They named the procedure the Hitchiker’s arteriovenous fistula.
The doctors said this new site has better durability when compared to other access sites. The doctors’ results with 31 dialysis patients over a five-year period were featured in December in the International Journal of Angiology, a peer-reviewed journal dedicated to the diagnosis, treatment and long-term management of vascular and cardiovascular disease.
The team has since performed over 50 successful procedures. Maharaj, a vascular surgeon working at the Caribbean Vascular & Vein Clinic at St Clair Medical Centre, said the main cause of renal disease and renal failure in Trinidad is uncontrolled hypertension and diabetes.
Diabetes, he said, affects more than 11 per cent of the population. Maharaj explained that the access point is created through a procedure called an Arterio-venous fistula which involves surgically joining an artery to a vein.
The vein is then punctured at two sites for the blood to flow from the body to the dialysis machine, which purifies the blood of waste products, then it goes back into the body.
He said a surgeon tries to go as distal as possible in the upper limb because access points have a shelf life. “So the teaching is you try to go as far down the limb as possible so you go by the wrist,” he said.
He said, “Traditionally, you go by the wrist or you go by the elbow but these things have a certain shelf life. Now if you go at the wrist you cannot go any further down the hand to create a fistula if it fails because it is condemned now. Anything further down from where your fiscal is cannot be used. So you could imagine a young person or someone with a long life expectancy who has a fistula for whatever the reason but in the elbow, you can’t go further down the arm. Because there is a shelf life to them you can run out of spots to put the fistula.”
Before the doctors found the new site, the furthest recognised access point on the upper limb was just below the thumb.
The doctors set off on a quest to find a more distal site on the hand and in doing so dissected several cadavers. They then discovered that fistula was possible at the back of the hand between the thumb and index finger.
“We have gone the furthest this operation has never been described anywhere else in the world before,” Maharaj said.
Noting that their first procedure was performed on a 46-year-old driver who died from uncontrolled diabetes, Maharaj said, “Based on the anatomical site of the fistula and his job as a taxi driver, we dubbed the procedure the Hitchiker’s arteriovenous fistula. You see it good when you put your thumb up like when someone is hitchhiking.”
Dialysis alone can cost a patient approximately $150,000 per year.
Maharaj added, “This does not include the cost of medication or the creation of and maintenance of dialysis access. While we have researched a new surgical access technique, much work needs to be done in preventing patients from ever developing renal failure.”
The vascular and vein clinic offers several state-of-the-art techniques to open failed access sites, but it is expensive as a stent alone can cost $15,000.
Underscoring the importance of early detection of diabetes and hypertension, he said it starts with the implementation of screening programmes geared to the at-risk-patient.
Maharaj said another critical aspect is educating patients and encouraging compliance of treatment and lifestyle changes.
“While we are honoured to have described and added a new surgical technique to the world literature, the team would much rather patients never reach the stage of developing renal failure and its therapy, thereby requiring the agony of lifelong dialysis,” said Maharaj.