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Patient Experiences of Interventional Radiology

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Leading research at the Lister helps keep renal patients dialysing well – a patient’s story

You can read the story below or via the link above:

 

David Robinson, a 67 year old retired butcher who has lived and worked in Bedford all of his life, saw things change for him significantly in the summer of 2015. That is when he was referred by his local diabetes team to the renal service at the Lister hospital in Stevenage.

They discovered that his underlying medical conditions – diabetes and cardiac disease – had led him to experience progressive renal failure, which if left untreated would have threatened his life. In preparation for David to move on to haemodialysis, the Trust’s vascular surgery team created what is called an arterio-venous fistula – a connection between an artery and vein – in his left upper arm to allow his veins to develop so that the needles necessary to support long-term dialysis could be inserted.

Whilst under the care of the renal team, David was admitted to the Lister with a severe chest infection that turned out to be pneumonia. During this two-week stay in hospital, it became clear to his doctors that he needed to move on to dialysis quickly.

David takes up the story:

“I’ve had diabetes for a while now and generally speaking I’ve managed to do okay and lead as normal a life as possible. But back in 2013 I began to get swelling, particularly in my right leg. On one occasion when I was admitted to my local hospital here in Bedford, 13 litres of fluid was drained off.

“I felt okay at the time, but my leg continued to swell and I had to wear surgical stockings to help with that. There was also no apparent reason why the swelling was happening. But after a while, my diabetes team began to worry that it could be linked to kidney disease and they referred me to the Lister, where I was reviewed by one of its consultants.

“It was then that I discovered that despite feeling fine, my kidneys were not working. In fact I had what was called progressive kidney disease, which meant that unless something was done about that, the condition would just get worse and could threaten my life.

“The recommended treatment was dialysis and I opted for haemodialysis, which involves removing excess fluid, salt and wastes from the blood – effectively doing the job done by my kidneys. I had the procedure done to have a fistula created in my arm, but events overtook me when I was admitted to hospital in April 2016 with pneumonia.

“It took two weeks to recover from that and the renal team told me that I needed to start on haemodialysis right away.”

Whilst fistulas are the most effective means of supporting high quality haemodialysis, they can suffer problems – such as blood clots linked to a narrowing of the vein being used. Left untreated, the quality of dialysis reduces and the fistula can become unusable.

Spotting problems and addressing them early ensures that the fistula continues to be used and the patient experiences good quality dialysis. At the Lister, the renal team works with interventional radiologists to treat fistulas that have become compromised.

Narrowing of the vein – which is called a stenosis – is now treated using a technique called a fistuloplasty or venoplasty. During the procedure, the patient has a local anaesthetic to numb the area and sedation, if required. A small tube called a sheath, which is around 2mm wide, is guided into the fistula. Guide wires are then used to insert a catheter with a special deflated balloon in to the tube, which is then inflated to expand the narrowed segment of vein.

More recently, the Lister-based team has been using a special drug-eluting balloon, which works by inhibiting the growth of cells in one layer of the vein, which leads to narrowing. This approach means that the treatment is likely to last longer, ensuring that patients experience better quality dialysis and longer intervals between such procedures needing to be carried out.

Reflecting on his experiences since April 2016, when he first started dialysing, David continued:

“I attend the Bedford renal dialysis unit three times a week and have done so for over 18 months now. In that time, my fistula has had problems on three occasions – most recently in July of this year. Although I have to go to the Lister, it’s a simple, painless procedure that I know keeps my dialysis on track.

“The team at the local renal unit and their colleagues at the Lister have done a great job looking after me and although dialysis takes up a large chunk of the day – I’m on the machines for four hours every visit – I continue to try and lead as normal a life as possible. The next step will be to have a conversation with the team about whether or not I am suitable to go on the transplant list – but for now, I’m concentrating on keeping well and enjoying family life!”

 

Contents

  1. The 30-minute op that can save diabetes patients from losing a leg - so why aren't more patients being offered this?

The 30-minute op that can save diabetes patients from losing a leg - so why aren't more patients being offered this?

http://www.dailymail.co.uk/health/article-4683418/The-op-save-diabetes-patients-losing-leg.html

 

 

The 30-minute op that can save diabetes patients from losing a leg - so why aren't more patients being offered this?

  • Last year, Graham Baker, 52, a carer from High Wycombe, Bucks, faced the prospect of losing a leg below the knee, a complication of his type 2 diabetes 
  • Last September he had a 30-minute procedure called endovascular revascularisation at the John Radcliffe Hospital in Oxford, and his leg was saved
  • It involves feeding a wire into the affected artery with a balloon and a stent which squashes the blockage and holds open the artery



Read more: http://www.dailymail.co.uk/health/article-4683418/The-op-save-diabetes-patients-losing-leg.html#ixzz4zoUTiGhE 
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Last year, Graham Baker was facing the prospect of losing his left leg below the knee, a complication of his type 2 diabetes.

Poorly controlled blood sugar levels had encouraged the arteries in his left calf to fur up, and this was obstructing the blood flow so much that the tissues and bones in his lower leg were being starved of blood and oxygen.

‘I had a scan to monitor the blood flow in my left leg and was told that without surgical intervention, I would likely lose the lower part of my leg — my years of poor diabetes management had basically blocked up the main artery,’ says 52-year-old Graham, a carer from High Wycombe, Bucks.

But specialists said they could save the leg — and it could be done under local anaesthetic in less than an hour.

It involved a newly refined procedure that clears the artery of blockages. Graham — who is married to Beryl, 53 — had the procedure, called endovascular revascularisation, at the John Radcliffe Hospital in Oxford last September and his leg was saved.

There are many people in the same position who could also benefit from the procedure, but don’t.

In fact, new figures reveal that one person a day needlessly loses their foot or leg because this simple procedure isn’t more widely available.

Blockages in the blood vessels in the legs (known as peripheral arterial disease) is common, but people with diabetes are particularly prone. This is because nitric oxide, a gas we all produce that helps keep blood vessels healthy, becomes less effective in the presence of repeatedly high blood sugar — as can occur in diabetes.

As a result, the blood vessels are at risk from inflammation; this in turn encourages the build-up of fatty deposits called plaques, which ultimately impede blood flow. While this affects all the body’s blood vessels, the effect is pronounced in the legs because the veins and arteries are longer.

As the blockages can hamper the blood supply, which would normally help with healing, a minor injury to the foot or lower leg can develop into an ulcer and infection, which can spread to the bone. Once there, the infection cannot be treated with antibiotics, meaning amputation is the only option.

Every year there are around 12,000 lower limb amputations in the UK, the majority of which are for people with diabetes.

‘Without adequate blood supply, in diabetics otherwise minor ailments, such as ulcers, can lead to the loss of the foot,’ says Dr Raman Uberoi, a consultant interventional radiologist at the John Radcliffe.

‘Increasing the blood flow even temporarily can help.’

Endovascular revascularisation is a simple way to do that. It involves making a small incision in the groin, then feeding a wire (guided by X-ray) into the affected artery.

A balloon and a stent — a tiny mesh tube similar to the spring in a pen — is inserted over the wire to squash the blockage and hold open the artery.

The stents are often coated with the drug paclitaxel, which helps to prevent the build-up of scar tissue that can lead to re-narrowing of the artery.

The same technique is used for treating blocked arteries in the heart. ‘In a straightforward case, which most are, the process takes only 30 minutes,’ says Dr Philip Haslam, a consultant interventional radiologist at Newcastle Hospitals Foundation Trust.

Data shows the procedure is successful in 85-90 per cent of patients 12 months later.

The technique, recently refined so even small vessels can be cleared, has better outcomes than traditional bypass techniques that involve opening up the leg to remove a vein that is used to bypass the blockage, says Dr Haslam, and studies show that patients who have endovascular revascularisation spend a third less time in hospital and are 12 per cent less likely to need an amputation than those who have a bypass.

So why aren’t more patients being offered this?

The problem, says Dr Haslam, is there simply aren’t enough interventional radiologists — specially trained X-ray doctors — who can perform this type of image-guided surgery.

‘We need to double the trained IR workforce from 433 to nearly 1,000, in order to meet the current demand, never mind the future demand,’ he adds.

‘We need more funding dedicated towards training doctors in this area,’ he explains. ‘Since it’s a quick, cheap, effective and largely painless procedure, this needs to be addressed.’

The procedure is available at most, but not all, major city hospitals. And Dr Uberoi, who is president of the British Society of Interventional Radiology (BSIR), warns that as the number of diabetics in this country — currently four million — continues to rise, ‘the demand for interventional radiology procedures to clear arteries will be even more acute’.

He adds: ‘Crucially, you’re avoiding a whole heap of extremely serious complications further down the line with a quick and painless procedure, with obvious benefits to the patient as well as to the NHS.’

Complications from the procedure are rare, he explains. Occasionally the artery can’t be unblocked because of the degree of plaque build-up.

‘Sometimes the narrowing in the artery can embolise — or break into pieces — as a result of the procedure, and flow off to smaller blood vessels where it can cause further blockages,’ says Dr Uberoi.

‘If the blood vessel is too blocked, open surgery is needed, but that requires longer hospital stays, and carries a greater risk of infection.

‘Compared with endovascular revascularisation, it’s a far from optimal option.’

Nikki Joule, policy manager at Diabetes UK, agrees that people with diabetes need more access to such procedures. ‘Diabetics should have the best possible care and support from a multidisciplinary footcare team who can deliver the best results, including access to specialists who can repair damaged arteries in legs and feet.’

Graham, who’s had type 2 diabetes since the age of 36, had already had a toe amputated in 2013 when in August last year he developed redness and pain in his left foot. Scans revealed that this was due to poor blood flow in the artery supplying it.

He’d also previously suffered an infection in his second toe and the metatarsals — the long bones — in his left foot, and had them surgically removed.

He was surprised at how straightforward the new procedure was. ‘I couldn’t feel it at all, and I was awake throughout.

‘When the surgeon got to the blockage, he inflated a balloon to widen the artery, and the pain in my shin — where the blockage was located — was excruciating for three to four seconds,’ he says.

Graham was out of theatre within 45 minutes. ‘The consultant told me it had been a complete success,’ he says.

He was able to walk that afternoon and was discharged from hospital the next day, and adds: ‘My left leg was saved, and for that I’m eternally grateful.’


 

 

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