The Battle Against Cholesterol – Chapter 4 (Text Only)

Thank you for joining me again in this on-going story of cholesterol and lipo-apheresis. As you may remember from the previous chapters, Kevin went through the process of getting a hemodialysis catheter installed and had his first lipo-apheresis treatment. In today’s blog I will discuss the fistula surgery and what happened when the first cath clogged. If you would like to see the fistula pictures, see the "photos included" version. Also, Kevin’s experiences are unique; always discuss medical procedures and all medications with your doctor.

Kevin was settling into a routine of dealing with the cath, but he was looking forward to getting the fistula done. The vein mapping and scans revealed he had great potential for a successful fistula since the diameter of his vein was almost 5mm (7mm is the target for a fully mature fistula). It also had the potential for being viable for many years since Kevin was strong, healthy, and it would only be used every other week. When Kevin made the appointment for the surgery, he was told it would be at least three weeks out since the surgeon was totally booked. Kevin accepted the date and told the scheduling coordinator to call if they had an earlier opening.

As luck would have it, Kevin received a call a few days later asking if he could take an opening the following day (he gladly accepted). It meant I had to miss my cousin’s wedding, but I was happy we would be one step closer to getting rid of the cath. The day of the surgery went well; the hospital was running ahead of schedule (how often does that happen?) and the procedure only took 45 minutes. We went home a half hour later when they were sure Kevin wouldn’t bleed to death (that’s pretty important). I did have a scare when we were headed home since the tiny blood spot on the bandage was increasing in diameter. 


I called the nurse when I got home and she assured me that was normal to see. As long as the entire dressing wasn’t covered in blood, Kevin was good to go. Later that day I felt Kevin’s wrist. It was like he had a tiny motor inside…it was very strange! We removed the bandage the next day and saw the incision covered with the suture bandage. What we didn’t see was a huge, bulging vein in his wrist and lower arm like the medical literature portrayed. It turns out it takes a few weeks (at least 8) for the fistula to get to a point where it is mature enough to use. It has to be a certain diameter (7mm is the target) and it has to be strong enough to tolerate being punctured by the 17 gauge apheresis needles. The surgeon also told Kevin that if the fistula didn’t come to the surface, he would need to do an additional surgery, possibly two. We were hoping that wouldn’t be necessary.

A few days after the fistula surgery, Kevin went for his second lipo-apheresis treatment. This time it took about 7 hours. We had food with us, but not enough to last all day. The cath developed a small clot on one side, so Anthony had to use extra heparin just to get a minimal flow. It was a slow, painful treatment for Kevin. By the end of the day he was queasy and in pain from the cath being manipulated.  After a discussion with the doctor, Anthony scheduled us to come back in a few days so he could inject more heparin in the cath to prevent a total blockage.

Three days later we were back at the dialysis center for the heparin injection. Anthony could barely get any flow on the “slow” side and could not get any blood to pull out, so he called the nepherologist. She advised Kevin to go to the vascular access center for further analysis and troubleshooting. As luck would have it, they had an opening that afternoon. We rushed across town to get there in time. The nurse finally took us back, and she had Kevin fill out more forms. The amount of forms and paperwork seemed strange since we expected they could do a quick flush to get the existing cath flowing again. Instead they informed him it would be totally replaced (now all the paperwork made sense). We were both crushed. Kevin wanted the darn thing out. To have it replaced was a huge setback mentally and physically.

After waiting anxiously for about an hour, I was called back to recovery. Instead of Kevin sitting up and looking alert, he was laying on his side. His legs were twitching and he was not lucid. I couldn’t get coherent responses when I asked him what was bothering him. I asked the nurses to get the doctor; this seemed very wrong. The doctor told me he injected a dose of Phenergan directly into the cath to quell Kevin’s nausea. Unfortunately it resulted in an allergic reaction. It took over an hour for Kevin to recover enough to leave the office. The traffic was terrible (6:00 on a Friday evening…not a surprise), so we decided to eat a quick bite before going home. Kevin was agitated and confused throughout the meal. (The next day he remarked that he never remembered eating his food and was confused by the sight of an empty plate.) It took until noon the following day for all of Kevin’s symptoms to abate. We marked Phenergan as an allergy on his med sheet.

A few days later, we went to the dialysis center so one of the nurses could give Kevin a heparin injection in the new cath to prevent clotting. This would be the routine (a heparin injection) every 4 or 5 days as long as Kevin has the cath. Under normal circumstances, people use these types of hemodialysis catheters for kidney dialysis. Those patients are going to the center every day or every other day for treatment, so the cath never has a chance to clog. Because Kevin went every other week, the chance for clotting was much greater since heparin breaks down after a few days. He went to the center the day before his third lipo-apheresis treatment to make sure the new cath was still flowing properly. Anthony was able to inject the heparin, and when he tested the flow, it was much better than the previous cath. Kevin met with his doctor and let her know this cath was more painful than the previous one. She examined it and realized one set of wing stitches broke. This allowed the tube to twist in on the other set of stitches causing irritation. The doc snipped the second set of stitches (giving Kevin immediate relief) and told us to keep a small Band-Aid over the tube to prevent it from moving too much.

The following day, Kevin went for his third apheresis treatment. The new cath was flowing much better, and Anthony pushed the machine to a higher flow rate. Suddenly Kevin became extremely sick as the machine kicked into a higher speed. Throughout the treatment he could not shake the nausea. Thankfully the treatment was quick. Anthony was able to treat 6,000mL of blood, the highest volume so far. 

Determined to find out why he became so sick and why he had a constant, low-level “car-sick” feeling, Kevin did some research. He discovered that the cath was most likely stimulating his vasovagal response. A few nights later Kevin was lying down and realized his motion sickness was much worse. He rolled onto his right side and felt very uncomfortable. He rolled onto his left side and started to feel his heart slow down and had difficulty breathing. He sat up and the symptoms abated. He called the nepherologist the next day and explained what he experienced. She told Kevin to go to the vascular access center to have the cath removed immediately since it was now endangering his health.

We were very happy to see the cath removed. The nurses were very nice and allowed me to watch the removal. As they pumped the bed up so they could work on him, Kevin started getting nauseated again. They waited until he felt stable to start the process. One of the senior nurses injected lidocaine into the skin where the cath tube exited. She waited until the area was numb and proceeded to break the adhesions. Once it was loose, she pulled the entire cath out in one smooth motion. I could see in Kevin’s face that he instantly felt better. Just to test, the nurse raised and lowered the bed; Kevin felt no nausea.

The good news was Kevin didn’t have to put up with the cath anymore (he celebrated by taking his first real shower in over a month). The bad news was he had to suspend his apheresis treatments until the fistula was ready to use. In tomorrow’s blog I’ll talk about the second fistula surgery, why it took nearly two months to resume the treatments, and the scare we had while waiting.