Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Good evening, everyone. My name is Chris. I'm an F two, um, down in his team on tonight, the've ning, Or if you're watching on capture, whatever type of data is we have a fantastic talk from Dr Linda. What? Kinze, who is a senior registrar training and adult general and pediatric Eye, are based across Glasgow and said Norman Street in London. And so she's going to give us a flavor of of renal disease. And, um, how high are, um, consultants and registrars A particular involved with the procedural side of managing and vascular say dialysis, vascular access. And so, without further ado, I will have over to Linda. Thank you. Okay, So did you know everyone? So thanks for the introduction. So yeah, I'm Linda Walk ins on my chest E five interventional radiology trainee in the west of Scotland treating scheme. And tonight, going to talk a few. But if you different things in or really to to Interventional radiology is role in vascular access and and renal dialysis. So the end of the session are essentially to give Unova of you of central venous access and it uses on. Then we'll focus on the different canes of access. They're used in dialysis on the way the IR is involved in them. Okay, on at the end, I'll cover a few more kind of complex ways that I archangelica. But this is absolutely for interest on D isn't really something that you need to worry about right now. So it's that right, considering why we may want central venous access so it could be relevant in, you know, every situation from the emergency situation right through t even kind of palliative care. I'm really everything in between. So in the emergency situation, central access late. She give large volumes faster for resuscitation a at least for several teeniest of administration of medicines, including things like you know, drops on. Also, let's and visit Monitoring am happen as well, so things like central venous pressure for patients were admitted to hospital acutely. It can be useful in patients who may be had previous chemotherapy or patients who use IV drugs on have difficult or thready peripheral access but need IV therapy such as antibiotic treatments. And some people need longer term access and constantly replace. And cannulas would either be traumatic or just not practical or with leads to the peripheral veins. Becoming more difficult to some examples would be things like disk itis when a patient needs it least six weeks of IV antibiotics on Previously, this was a really common thing in patients with cystic fibrosis. We needed regular courses of antibiotic, but I say we really noticed the difference and a decrease in the in the need for this with the advent of some of the newer cystic fibro. Take drugs. Um, lastly, there situations where you need where central access is specifically required on. That could be because of the nature of the medication or treatment. On examples of this, our dialysis renal dialysis on total parenteral nutrition as well. Obviously none of this is an exhaustive list by any means. So what? I mean when I say central venous access. So it's about where the end of the lane is, rather than where the start of it's so for central access. We're talking about the length that being in, that's the women. Today it lanes up being the superior vena cava in the right atrium or in the inferior vena cava. So we have a few roots by which to get their some of what you can see on this diagram here, um on the Chosen will depend on the indication whether they're being previous lines patency of the vessels on also what the potential future treatment options are for the patient as well. So we'll go through some of the common central venous access. So a peck is our peripherally inserted central venous catheter or differently inserted central venous cannula. So a certain extent it's named describes it. Okay, so it's becoming quite common for hospitals to have a vascular access service to insert these, and these are often radiographer or a nurse A or a combination of both. In terms of her lids image, Gaitan's is used in the peripheral venous, punctured with ultrasound guidance, and then sometimes fluoroscopy is used to track the wire. But there's also e c G insertion of pet planes as well, where the C G gauge Ince's used. Then electrodes are attached to the patient's chest on the machines, able to detect when the wire is that the cuboid real junction. Some departments will routinely get chest actually, after that, others just where they're concerned and get us, that should equate variable. So the venous and not to me is generally much more video ble and people than art. It'll anatomy is, but usually there are see a mean upper lung veins, so folic vein. But if you've seen on basilic vein, any of these could be used for a peculated. It really doesn't matter. But the basilic on the inside of the arm is often favored first. This is an example of a pickle e. This one gets in measured on, then cut the length before it's inserted. Um, others conjugate connectors on the outside once they've been caught on the outside, there's video bility in the number of lemons and the dressings and things that replied. But this is what it might look like. Um, on the outside, And this is one that's been placed into the are you? If you have to look a chest X ray for the PICC line, this is what you want to see. So you want to see a nice, smooth arc going from the upper limb. She here. So from the upper limb here, right round on, with the tip projected either over the sec at the Cutivate, your junction or the tip just in the right atrium. This is an in graphic form, just in case. It's kind of not projecting very well so that you can see a nation clearly. Here's one that you don't want to see. So and if the If The PICC line is coming in nicely from the arm but then goes north, then that means that the type of that has ended up in the internal jugular vein rather than rather than going around to the X PC, and then this one is a bit more tricky. But the lane essentially should be very typical. Okay, so it should. It should come around and then taken a street course until you see the tip of it here is going off to one side and on. It's likely in these, I guess, system, which is a much smaller Veen. So isn't one that you want to be putting and more toxic drugs into a and you're also not gonna be able to put as large volumes as well so temporary Central lanes are commonly inserted by anesthetics I to you on the emergency department there for short term use, just to the risk of infection on that could be put really into anything but into the internal jugular, subclavian, vein or family. And so this is an example of, ah, multi women. Temporary, essentially. And but there's other temporary things, such as a vast cath, which could be used in for a temporary dialysis. It's essentially much bigger caliber and but the same principles. So we'll know. Look at the ones that I are are more involved with so tunneled central venous access. What we mean by that is that a tunnel, Blaine, is where the lane travels from the veins through the subcutaneous tissue so that the skin exit say is separate from the vein entry site. This reduces infection and makes them much more do toble. So they lasted much longer in the case of a port, actually doesn't exit the skin a toll on our show you some pictures in a second, and so we'll have a little look. Heckman Lanes, which you're just a brand really off smaller caliber since relaxes and ports which of the ones that are body's under the skin and on dialysis catheters. So it doesn't really matter of which one is they're all inserted didn't roughly the same week, so the Venus punctured under ultrasound guidance. I'm a gauge. Why you're past under fluoroscopy. Um, you basically want to get your game. You used fluoroscopy. It's trying to you get a wire into the IV, see? But you can actually you able to see your gait wire passin to the vein or Notre saying so Here. The vessel is in a longer TUNEL plane. So you see it going all the way along. The needle's coming into the vein just here. Tip of the needle is here on this is the wire going off off during the vein, the tractors and dilated. And I think all the pillowy sheath is inserted. So a pill every she looks about like this. It's got a central a central trip central day later. Then this is put in over the wire So you have a wire coming out of the back here on when it seemed to put the lane in the central day later comes out along with the wire, leaving a whole of trip. But you can put Blaine don't possibly in through it. The sheath, the pill away part is them broken. I like you can see here. I'm literally peeled away like a been on a few and away from pulling okay before. That's don't know. The lane is tunneled to an appropriate sites. So this is what and what I meant here. So billion is coming into the vein here. This is a subclavian line. Zillions coming into the vein up here. But then this is tunnel through the subcutaneous tissues on this is where the skin exit say is on the chest wall. This is AM all done under local anesthetic, but it can definitely make people about squeamish. Okay, so, um, what one of the nurses that I work with She hates tunneled lanes because she just that the actual tunneling part of it came. It looks like something's moving beneath the skin. And she just she just absolutely hates that absolutely hates it. So it can definitely make people a bit squeamish. So once it's through the tunnel, it could be measured over the chest wall using fluoroscopy and cup two sizes appropriate. Some of them come a Zen precise than you have to choose your size before you start on, then yet so it's inserted through the pillow. We like we talked about so you should end up with lovely pictures like this. So we've got a race, a deadline on left sided blame. You can see that with the left sided lane. It's the intravascular portion is a little bit longer, and there's no kinks in the chipping on both of the lane. Tips are projected over the the race. A delay in. It's probably at the 10 of them. Give it your junction on on the left. They delaying the tips in the very itchy um, so both of these are appropriately placed. So are the differences between these lines. Okay, so ah Heckman Lane or it can a standard. A ton of laying that's not for dialysis comes in different diameters. It could be multi women, although most cases a single women is enough and reduces the risk of infection. So if you can get away with just having a single women, that's what you should be putting in, and they're cuts length on. They're used for things like chemotherapy put into a nutrition long term antibiotics. Ports are similar in in terms of them being relatively small caliber. But there's actually a little AM a little port that since after beneath the skin on the skin is stretched up in over the top. So the set in the subcutaneous space they can last for years, and they're very discreet. I'm one of the big advantages of them is that patients could do things like swim, um, and take a bath, which you can't really do because of the risk of infection with A With some of these other trouble, planes and dialysis cancers are much larger than two limits for the dialysis machine on they come in standard lens, so they're not trim to size. So you need to choose a size that's appropriate for the patient on to make the size of the tunnel the length of the tunnel appropriate as well. These are only used for dialysis. All of them can have blood taken from them. But different places have that one rules about that. Okay, so I would be careful before you went rushing into drug border over dialysis. Catheter was checking that no one was going to yell at you first. So this is what Heckman Lane looks like so you can see that it comes out of the upper lateral chest wall, but you can see the step here up in the neck as well. So you get the most. So the stitch here is where the vein was accessed in order to put end, and you can see that it's been tunneled under the skin here with the exit. Stay here and then just curved under in under addressing, This is just a little It's called a biologic and and it's a little on a disk, and that is antimicrobial to try and reduce infection. This leg has an awful lot of women's. I don't think I've ever put in a triple women and triple women letting that seems seems like over But anyway, and that's not this is what a port looks like so they could be metal or plastic on. They have this diet from over the talk here, and this is the bet where the needle goes through. This is self healing. Die from on your only like to put very specific needles into um, okay, they're called keppra needles. Patients will yell at you if you go towards it with a needle that they know is not the right needle. Eso. It's only these special clipper needles that have the whole on the state, so you advance it in until you feel it up against the back wall of the port. That's fine, because the tip of the needle isn't were. And you're able to get blood back from, um but through from it's out of sight. And so you just advanced the needle through the skin and into the diaphragm off the port, and you can hold the port ST E M to help you to help you do that as well. On this is what it looks like on a chest radiograph so you can see nicely. The port here s so it's got waiter, a waiter base with these holes that you can use to stitch it in place. This is the diaphragm on the top. And then this is the tubing again. Nice, smooth carbs. New kinks on the tip is located every each. So dialysis lanes are. They have the two limits. There's usually a rate limiting a bloomin on their much trunk. Here. This is what it looks like a chest X ray and just compared with some of the lines that I've shown, you already hope you can appreciate that just the diameter of the caliber of this tube is is much bigger and down the other ones, so we'll just talk about dialysis for a quick second. So we're focusing on hemodialysis here, where blood is taken from the body. Um, um, essentially cleaned through a machine on, then sent back again through a second access port. And don't ask me any more questions about dialysis, because, to be honest, we have really stretched my knowledge with that description. Okay and him. But don't forget there's peritoneal dialysis, too. Okay on him. Prepared to meal dialysis, there's, Ah, there's a catheter access into the peritoneal cavity on dialysis. Fluid is flushed through. Transfer of waste products happens across the periods, and you're leaning on the waist. Fluid is collected again, so some people present with horribly key I that never gets better and need long term dialysis. But in most cases, it's a slow progression of a chronic kidney disease. On dialysis, access is ideally a planned thing in advance. A ultrasound V mapping or occasionally a venogram where we get access with the cannula and inject contrast to see the veins is done. We aim for the non dominant arm, usually try to go as peripheral is possible so that the options for the future preserved so they can move up the arm if required. Usually a fistula is considered his first like full of by the insertion off. Synthetic material in the form of a graph lanes our last lanes to their last atrially. Because of the problems with infection, they also cause central venous tunnel assess, and things tend to favor upper limit access over laurel um, access for dialysis. This is partly because your risk of infection is Lord, if you stay away from the groin region. Um, but also, you want to try and stay away from him the laurel, um, vessels, because you don't want to damage the Elliott vessels in case the patient gets a renal transplant in the future, and it needs to be clumsy on down there. These patients need a multi disciplinary approach. Okay, so ours involves reading are specialists sonogra for's I are vascular surgery, renal transplant surgery on, you know, anyone else is kicking in my body, but but the multidisciplinary team is really crucial because there needs to be. You need to know what the long term plan is And while you're deciding what you're going to do and on these decisions need to be need to be need together. So ultrasound vein mapping is a total mess no more, because it's not just the veins that we look at. We look at the arteries as well. You need to know your upper lung vascular anatomy. I'm basically the ultrasound in the this scan, the sonographer or the radiologist will give a descriptions off all of the veins and arteries, so usually the the owner in the radio and then your your break. Your basilic uh, I'm Catholic. Well, they want to know the size is off the vessels. They want to know flu information in the vessels, and they want to know how much after it's got off the disease. There is a swell on. Essentially, you do. You do both proximal and distal so that they could make a decision on a fistula is on abnormal connection between the vein and artery. So festival is this is the first special that I ever heard of. That was a good thing. Okay, so usually when we're talking about festival is we're talking about bad things. Okay, we're talking about, you know it'll recycle Festival is where people are just having constant urinary infections because he sees is getting into the bill on. These things tend to be either post impulse surgery or put some sort of really bad in inflammation or or effective tape thing. You can get traumatic Festival is and, for example, where there's been a broken bone and those kind of things so and this is a fistula that we create on purpose. So it's an abnormal connection between the artery on the V on. Essentially, What you want to do is you want to make the connection on the elected. Mature officially, could be looked up with ultrasound once it's made to look first in Aussies on this picture shows the connection between the artery and the venous. So here, this is the artery and this is the pain of the fistula. And you can see hear that this is the artery here. And then you've got this connection between the two on into until the festival. So has it matures? The vinca is bigger because the venous night cutting arterial flu on is being pressurized from the arterial state a little bit bigger is good, it makes it and we call that maturing. And we like that because you need to be able to get your dialysis needles into, and you need to have good flows through the fistula in order to get good dialysis. You get this kind of buzzing or is called a bruit that you can both feel. And here on it feels almost like there's like a little bumble bee, like buzzing around just under the skin on. If you come across a patient and who is on dialysis and has a festival and you've never felt this, then just ask them. Ask them if you can have a little fuel of the fresh jeweler and you'll see what I mean. Sometimes, though, m as in this a picture on the rate the dietitian could get a little bit of hand. Do you get these big aneurysm festivals and these air usually a sign of our option upstream problem like a stenosis on these, convenient as a jury can imagine, really quite dangerous on the the needs surgical like a shin. So if officially doesn't work or develops a problem that can be fixed, then I graft can be inserted. So we use the AC. You feel graft where I work. So it's a synthetic troop that again is inserted between the artery and the vein, creating an abnormal connection. So here's the artery here. Here's the vein here on the graft is going between the two. The graft itself was then directly punctured with the dialysis needles in order to in order to achieve any dialysis. Let's go in the arm, like in this picture, but it can. It can go with the femoral vessels in the thigh as well. So this graph test the layers that you could see nice and clearly am on. Ultrasound ain't so The image of the top is just showing the graft, as you would see it without collar on a with the difference the different layers of the graft or just in here on this is the skin surface here on this. Is that with college or no just showing that the showing the floor going through the draft. Uh, we can also assess these by putting a little troop into them on, then injecting contrast on. You can see this nice, smooth feeling with contrast really through the forearm on up and into the venous Well, so this is just a nice normal graph to ground picture, and we do. Some of these routinely s o in my department. We do routinely after gone six weeks after the graft has Bean put in just to see what it looks like. It's like Look for any released in your season, things like that on then it's quick comment. Some patients get a graph to come every three months. Some patients are stable and it's working well, so they get ultrasound surveillance and within a graft. A gun with the ultrasound suggests that there's in that there's a problem. So I our performance, similar interventions or both festiva a on draft so we can put a chip in them like it just showed you on. Take pictures just to make sure everything is okay. This is much more common and graft, usually for intervening on a infested. And then it's because there's there's a problem rather than just the have a look. Um, if we see it's the North says we can treat them with balloon angioplasty. If there's a recurrence, then assess. We can cheat with drug lifting balloons or drug coated balloons. Or we can use cutting balloons a swell to help prevent recurrence on. We can also put instance we're required is well, drug coated balloons are exactly what we see on the 10. The balloon has medicine on the outside of it. They're not to be used to actually stretches stenosis. So you stretches. The nurse is first of all with a normal blue on. Then you would put in the drug coated ballin on inflated on effectively Make the drug stick to the walls off the vessel. Take the balloon down on the drug helps and the vessel remodel. And in a more and more open, we essentially khatim billions also exactly what I see on this 10 they basically have could obtain a little reserve leads on the state of the blue. So you sleep the blend it cuts into the stenosis damages the vessel wall. Essentially, what you're doing with all angioplasty is that you're attempting to damage the vessel wall so that remodels better done add ready, remodeled. If I make sense. So you want you want the stenosis to remodel. So that is more pizza than it was before. So they're usually Lasix use at the state where the artery and draft a or the artery and vein meat. This is, ah, graft with an arterial stenosis. So here is the artery here. This is the anastomosis between the artery on the graft. This is the graft on, then that transitions into the patient's vein up here. So these you can on your posse. So we would usually try to undo posses, partly because we're in there with taking the picture. Nasal treat that. But if he's Ricard, they need tends to need surgical revision rather than anything else was much more common or venous side issues. So this is official ago. I'm showing multiple problems, so there's multiple that there's, uh, stenosis or maybe a spasm here. There's some stenosis is here this, but looks a bit the news. Is that a pseudoaneurysm? Is this an aneurysm? A portion of the festival goodness knows what all is going on, but there's lots and lots of problems here on, Really, it looks overall, like the fistula isn't really maturing because this vein isn't much bigger. And then the the artery that we can see here, we really want the vein to be becoming a bit bigger so that it can be used. So this is a case where there was a stenosis and its appearance is improved after angioplasty. So you can see this nurse is here on then This is what it looked like after blowing up a balloon inside it so you can see that it's gotten much better in this case is a really irregular, horrible looking stenosis here. So this this late and he was just the wire that we've am passed across the stenosis on. Actually, this was actually stented, which gave a really nice can a postoperative am appearance here. Okay, so you can just about make out the stent. If you look closely, you can see some of the shots, so some of the instances can actually be seen on ultrasound. So this one was in the venous outflow of the graft. So you can see that even the color flow not I was doing here on you can take measurements on measured the floor a through any stone or seizers. Well, to see if it's real or not, you can get on a jet phenomenon. Unchain Gisin. The doctor reformas. Well, this was that on him angiographic imaging on then Postangioplasty all looked much better. Mm. So in this case, this was in the venous outflow off a graft. Okay, so you can see you can just about make out that there's maybe some leers have a graft in here on these. We actually don't just the lineas anymore. So this record within six weeks. So that's that's the same stenosis again on this time it was stented on know we would send this. We would send this on the on the first on the first day graft A gum know, because we kind of learned that these these venous outflow it's the North sees they just they just come back. So we know promoted the stent. So there's some kind of graph specific problems as well, so graft can get rough inning or stenosis is within the graft itself because three times a week, your second relatively big needles into them. So again, sometimes you can see this on ultrasound and see you can see instead of the pictures actually earlier, nice and round with Blears. This is all squashed own, and that's from the sticking the needles and on in until formula on you can see it here on the geographic images on is this Resistance is in a graft. Treated it with a balloon. So this is the wire wires through and through the graphs stenosis. Here we put a balloon up in it on it looks much better. So this was this was a good result. You can also get through bosses of the graft. So on this image here, you can see all these kind of white bets are filling defects through the draft on this is essentially the blood clot. Please need to be decoded. Now, there are I our methods of doing this in my workplace. The surgeons do the declaw on. Then we come and take some pictures and put in any stents or treat any India's that that need some treatment So you can see the improvement here between the picture on the site, on the picture or this side after the equal. Over time, the grass can get kind of wouldn't tear in. The lining gets damaged from repeatedly sticking needles in it again three times a week. Right? Big needles. I'm just doing here this gonna swing of the graft. There's contrast on then a Lear without any contrast on them or contrast. And this is because the layers of the cup I've come apart on this contrast going between little ears of the draft. So this is called delamination, and it's treated him with stenting inside the draft. Um, and a lot of the time, what you just trying to do is just keep these things running. Okay, these patients need the dialysis on, but you're just trying to keep whatever access they've got going for a long as you possibly can, so that you can preserve the other access for when they potentially need it. So when I move into some of the slightly more a complex or their stuff when it comes to contention, Radiology in dialysis is intravenous access. So there's a couple of the bases on the market night for in device killer TV or venous fistula creation. There's a recent review that I've just been the purple in here, um, looking that kind of competing these techniques to surgery, and if you want to take a closer look so that the Medtronic Ellipsis device eso works using basically a single puncture through both vein on our tree on then insert the device so that it's positioned on either side of the two. So one side in the artery was it in the vein. You include it together on a thermal energy is used to create the anastomosis. So these are the two bits together here on the energy on that creates a whole the whole is them ballooned with non to plasty bell in. Um, Andi, you've created this a the special, um, that you wait to mature like you would any other fistula. There's also the BD we've like Q device. Um, so this is this is what was making punctures or in both the artery on the vein, the device. There's two sides of the device. One if you did it, one fed into each one and they're trying to teach other where you want to meet the anastomosis by magnets. Okay, so you've got one in the artery here. One in the vein here. They're attracted to each other, and then I think this uses Let me just check. Yes, this is really frequency ablation. Um, between between, the cartoon sees the magnet to create the fistula. So Centrum is access can get really tricky Okay, so, thrombosis. Since the nose is a huge problems on the connector, they can occur in grafts and fistulas. And but lanes in central vessels definitely spread on virtuous Try and you know you've got and you've got visible injury just by the fact that the line is they're on energy to nuclear Stasis by having a foreign body, and you've disrupted in disrupted the floor and things as well. Like these patients don't have normal clotting. But realistically, if these patients don't have access, they can't get dialysis on. If we don't get dialysis, they're not going to survive. So we need to make sure that we can still get patients well functioning lanes, even when lanes are what the problem, what the problem is. So this first picture here I am on the left is theoretically essential being. But the SPCA is barely visible because of a stenosis, so that's no says there's really quite tight and wouldn't allow you to get a pillow. We sheath am through two in, certainly. But if you get a wire through it like this, then you can put it on to your plastic balloon across that and do a do a venous plasty. Um, and once you managed to make the vein a little bit bigger, then you can get a lane and through on the patient can keep on having their dialysis. Sometimes there's no stenosis, but instead there's a complete occlusion so long as there's a stump of ain't for You to, um, for then you can bring something up from the Boston's. That's what's happened here. There's Castor come up from the bottom, and then you can use this. This is a very, very long a middle that we use, and I are for another procedure, and you could possible iron through this needle. So if you have access into the pizza but vessel came above, you could essentially stop through a new clue. Shin. Put a wire through on, then sneer that wire oats. And once you got through and through access from neck to growing, you can pass almost anything over that, and you're certainly able to get him to get a lane. And at once you've got stuff wire with through through access patients. Absolutely. Did you get it for less? So this is This is painful. On Also, computer video is well, it's not necessarily, particularly no 45 minute procedure in the and you love. You know, as there's also this device that I think is made by blue grass but sold by med it's in. Some countries on this is called the surface are inside out device. So again you come up into the inclusion from a from blue on. Then you have the skin marker where you want the wire to come out. So I eat where you want the lane to go into the vein. So you put the skin marker a skin marker on useful oscopy two lane, the skin marker up with the device on. Once you've done that, you press a button on the device on it will poke a needle, it's and it will come out through the skin, and you can then pass a wire from the femoral access re up, through and again, you think got last through and through excess again. The Lakers said You can pass almost anything. I am almost anything over. At that point on, techniques like this could be used to gain access for um, or all encompassing graft when, by the time you're in stage adrenal access or in stage vascular access. So this is a hero device. So hero stands for human dialysis. Reliable awful. One end is plumbed onto the vessel in the arm by vascular surgeon, and then it's tunneled on the other instance in the rate atrium. So you need to be able to get access through your through your occlusion or whatever. So we usually have a lane and say, too. So this, but is put into the re atrium. This but is tunnel that here vascular surgeon attach? Is this pet to the to the artery in the arm on? Then it's graft material again, like the efficacy that we talked about that comes. That's tunneled subcutaneously through here. So all of this is internal. All of this is on the insight on the tour, connected by a little connecting piece, usually around around the controlled ER or the clavicle area on then all of this graft, but here can then be accessed with the dialysis needles in order to in in order to get a good quality, good quality dialysis. This is what the true looks like him for the chest part, so it's quite distinctive. It's got these. It's it's thick on, but it's got this almost done, Um, actually competing. It's a way through as well. On the radio, opaque markers are the tip to I'm one last video. Where we've been known to help is when Lane is inadvertently put into an artery and state of a bean are some things even through a vein in em on in turn our tree. So this is recognized when the needle and wire is all that's gone in, then it could be removed. Impressed on. Okay, So if you're ever doing, uh, lanes, just ultrasound guidance on know where your needle tech is? Okay, um, And if it turns out that it's got into the artery pill press don't eat what he wrote it. If it's just the needle or wire. Okay, If you've already done some invitation or if the pill always been searching for the lanes been instructed, then that could be quite a big hole. Um, management options will depend on the size of the lane or the chief. Which artery is. But you're likely to involved with vascular surgery, and I are in the discussions about what in what you're going to do and so I know that there are a few different techniques, including you can get arterial access and put it on do plastic balloon and pill the lane and then inflate the balloon to essentially press from the state. I know of one case where closure device was used. So in that case, I think they're going through the vein and into the artery. So closure device was inserted Pills up against the art in you will, um, unused a used to seal off the artery and may just be indirect or toujeo puncture, actually, and I'm not quite sure. Um, Andi, sometimes they need to in vascular surgery repair as well. And obviously, the uses off these things in these contacts would be wildly off label. Um, on the other thing really to know is that if this is around the neck or the arch, then before you go into to do anything, the patient needs to be aware that there is a significant am risk of stroke. So am let's just summarize. So we've gone through some different kind of lanes, and the different uses that they have on the list is dependent on a combination of the indication on the Jewish in of treatment as well as patient factors as well. Vascular access services are usually nursery geographer, later becoming the first part of coal. They're in excellent least a golfer. Advaced. If you've got a lane that's not flushing or you can aspirate from or you're what you make the infectors on their get a great place to contact and usually extremely helpful. And real Dialysis can involve lanes, but also fistula on drafts. And I are has a rule in the potentially in the creation in the future is certainly the moment in the maintenance of management off the renal vascular access through mainly videos, and you passed it techniques on stenting I Our can help in complex situations where access is becoming a problem. Um, on a we could do these things like sharp recapitalization or use a use devices in order to prolong. Relax s so thank you very much. I got some special thanks to one of my consultants, doctor custody, who would give me access to some presentations that he's given, um, on this on this subject to help prepare the talk. And there's a few other references. There is. Well, thank you Well, listen, thank you so much. I was a fantastic session. We've got a few questions for you in the chapel ups of any but so first of all from Marcel. And he's just wondering with them Higman line insertion and whether you give antibiotics beforehand or no, we don't give antibiotics for any other lane insertions. Um, we give antibiotics if we are exchanging Elaine. By that, I mean putting a wire data lane that is already there taking it out and you laying over the same wire. Mm, yeah, Sometimes that's necessary because you've got a patient who you know is going to require lanes for, you know, years and years for for dialysis. And you're wanting to really preserve things for as long as possible. Other times you may create and your tunnel. But use the same and puncture site on things like that so we would give way, have a protocol on. We give antibiotics when we exchange lanes. But no, when we insert, that's really helpful and clarifies, Yeah, whether you you would give them sort of routinely, which isn't in case. Then the next question we've got is asking specifically about declaw ting lines And what do you actually use for decreasing lines? Yes, I know that there are certain fire are devices. The other place is a do you use, uh, our surgeons. Declaw are graphs. Um, so they will they call a graft open, and then it's a basically caster with the little balloon on it on. They shoved the catheter out past the clot, complete the blend and drag the clock right. And when it comes to lanes, you can use alteplase to to try and declot lanes, lanes, clotting. Is it usually the biggest problem? Um, lanes, Actually, the group what we call a fiber and sheath on the end of them on. That's that's actually a bigger issue than lanes, actually clotting themselves. Most vascular access teams will have a kind of alter, please. Protocol, um, and things like that that you can try a f l ain't is blocked, but you may faint critically if a lane will flush. But one aspirate that it's actually a fiber in chief. That is the problem rather rather than court okay on. But what I say when you say flush, but can't aspirated say, what is it causing the the deficiency and aspiration that from the way you're moving your insurance is, um, trying to think it's kind of a turtleneck on the end of the line. Okay, that's flapping in the breeze a little bit, Okay, when you asked me back on the line the fiber and sheath and basically becomes part of that vacuum on well shot or will flop over the end in off the linguine you aspirate. Basically, because it's mobile isn't kind of part off the lane. So that means that the interval of your lane is blocked and you're not able to, you know, able to ask me back on it. But you don't have the same problem if you're injecting something through, because it's going to push the fiber and she's out of the way and you're going to be able to, um, to inject through it. So basically like a one way valve, Okay. And then, yeah. I mean, the other question is, how many times you can declot have access lines. First place. That's more of a I Yeah, for the vascular surgeons. And how long is a piece of string? Yeah, exactly. Cool. And has anyone else got any other questions? they want to popular in the chart. Have on, uh, there's anything else you want to have, Linda, basically, you know, when you work in pediatrics being and curious there, If you go, if you want to have speak about that for just a couple of minutes faster, we give people a chance to ask anymore questions. Yeah, I guess there's a few differences in pediatrics. Big thing being the sites eso When I do an adult lane, I will puncture the vein. First, um, I'm past my wire to make sure that I'm a policeman. Pillory sheath. Really? To make sure that I know that I'm confident that I can get the whole that I'm gonna be able to get a building in. Then I make the tunnel. Then I could let you through and then put the put the people we through. And Children, though you don't particularly in the very little ones in the baby's the baby babies. Mm. You know, their entire circulating blood volume congee. You know, 300 miles 100 to 500 minutes, so every drop of blood counts and you don't want to have your pill Every sheath in place with little drips coming out of it while you factor and making the tunnel. You know, putting putting You're laying through the tunnel and things s o in the in the little ones in particular. But in practice, in all the pediatric patients, because you need to just have a system. You actually make the tunnel first you tunnel the lane on in. The last thing you do is you do your puncture, you put the pill away and so that you can almost instantly then put the lane in to minimize the blood loss. And that's one difference. Thea Other thing that stresses me out in pediatrics compared with adults is that they will quit casually. Removal ain't from the left side and put one in on the rate state on I'm going. But but But what's gonna happen on the left side now? Is that just going to close over because you have believed in there like, you know, whereas in adults, I would say that we work very hard to exhaust one possible access before we moved to another one. I guess that's maybe very specific to the dialysis. In particular, we we know that they're going to need to access for a long time on this is going to be our problem. And so so you definitely try and exhaust options. I think before before moving to another venous, I think maybe part of that, though, is that you probably. What do you bathe? Infection a little bit less in adults because in these unwell in the zone, well, kids, you know a lot of them have lanes because they're getting, um, chemotherapy. Or they're requiring a TPN and have, ah, Lord nutritional state and things like that as well. On do infection is a much bigger and bigger do. Really, um, in in kids from that from that perspective. So if you've got if you're removing a lane because am because there's infection or because it's not working properly, then you do probably want to make sure that as a completely clean the instead of in laying so that it lasts as long as possible and doesn't give it doesn't give the child difficulty, so they're they're definitely can a subtle sort of differences between between the two. Listen, thank you, Linda. And one final question not quite sure what the meaning is, but just regarding the fiber in and fiber and clots in mentioned off vibrant sheath. Really? And is when the fiber in forms do you scrape the line, I think is what they're asking. What do you scrap the line? Yes, I can answer pills. So? So, in terms of just getting rid of the lane if it it depends what is needed for, um, in a lot of cases, they're not relying on the lane for aimed blood that can maybe still do peripheral venipuncture er so if you're able to still get mets and n then not being able to get blood isn't always a big deal. It is a problem for dialysis lanes because you can't. You need to be able to aspirate the blood for it to run the machine, to be able to go back in. So for a dialysis, like you would need to exchange the lane or we can actually we can put a wire donut and actually put a balloon into the fiber in chief to disrupt that in on things like that as well, so am for dialysis. Then you would potentially need a You need a completely completely new line. But no, I didn't know in all cases, for for older things. And you can do a thing where you strip the line to try and get the fiber, and she's off. So this involves using, uh, am sneer. Um, essentially, you use the sneer to try and grab the lane and grab the fiber sheath and basically kind of pull off. I I have I've seen that attempted I've not seen it Work very well is kind of there in the in the literature, But I'm I'm not sure how effective it is. And it's not something that we would often am. It wouldn't be our goal to in terms of dealing with fiber cheese. Cool. Thank you for answering the questions. And once again, thank you for giving up your evening toe, give this talk and much appreciate. And it's Yeah, it was really fantastic talking. Nothing that she's in in the comments. Well, say have have you enjoyed it as well? And we'll, uh, well, end the recording there. Thank you. Have room for watching. Thanks, guys. Drive me