Pit stop clinic keeps vascular fistula patients off operating table

Every two weeks Maryanne Murphy could do little but comfort her daughter as her body succumbed to paralysis.

"It was like watching a battery dying," Ms Murphy said.

"Every couple of weeks she would go into a vegetative state and each time we didn't know if she'd come back or if she would die."

When Candice was 10 years old she was diagnosed with severe chronic inflammatory demyelinating polyneuropathy, a neurological condition that destroys the protective coating (myelin) around the body's nerves.

For five years she underwent plasma exchange to filter her blood through a central line protruding from her chest.

The line was keeping her alive, but it was a conditional lift for the once active child.

Candice couldn't get the line wet. She had to sit and watch, bone dry, as her friends went swimming in the 40 degree summer heat of her home town Leeton, NSW.

She couldn't shower and couldn't play the sports she loved in case another player accidentally pulled out the line.

"It really affected her," Ms Murphy said. "It affected the whole family."

The teenager underwent multiple surgeries to correct complications. Her mother gave up work to drive her to the Sydney Childrens' Hospital for treatment every two weeks. Every other week they made the three-hour round trip to Wagga Wagga Base Hospital so the central line could be flushed out.

"The toll it takes on Candice ... it was more than anyone should have to go through," Ms Murphy said.

In 2015, Candice's neurologist suggested she try a vascular access arteriovenous fistula. It involved a procedure that would connect a vein to an artery in her arm that would allow direct access to her bloodstream.

Most commonly used in patients with kidney failure who need hemodialysis, a patient's blood can be siphoned out via the fistula into a dialysis machine that filters out toxins, then pumps the blood back into the patient.

"I was really excited to know there was a different road I could take," Candice said.

It meant no more central line. But fistulas come with drawbacks, being prone to blockages and infection.

Repairing vascular fistulas were some of the most frustrating procedures Shannon Thomas and his fellow vascular surgeons had to perform, the Prince of Wales Hospital specialist said.

"We were doing tonnes of these emergency procedures on the sickest patients really late at night," Dr Thomas said.

The surgeries came with a high risk of complications, including heart attack, pneumonia, bleeding and rethrombosis.

???"These patients often ended up in intensive care or they would die because of access failure," Dr Thomas said.

"I thought there has to be a better way to do this. I really thought I could make a difference."

In 2013, Dr Thomas and his colleagues at POW opened a renal vascular access clinic (RVAC), a one-stop shop for patients on dialysis and other patients with vascular access fistulas, including Candice.

A multidisciplinary clinical team including a vascular surgeon, nephrologist proactively monitor patients for any problems. A vascular access nurse consultant oversees a patient's care, co-ordinates appointments, pathology tests, surgery dates and follow-ups.

The aim is to catch potential problems before they become life threatening so patients can avoid emergency surgery as well as long and frequent stints in hospital and the litany of possible complications that come with them.

"The way I think about it is like an F1 car coming in for a pit stop," Dr Thomas said.

The clinic has significantly cut the need for emergency surgeries and the number of days patients spent in hospital, according to a two-year review of the clinic published in the Australian and New Zealand Journal of Surgery.

The average length of hospital stays dropped from 10.71 days to 3.14 days, and emergency surgeries fell from over half to just over one quarter of vascular access procedures, according to the review.

The number of admissions dropped from 193 to 164 and the number of surgeries dropped 195 to 151 over the review period.

"The real benefit is keeping patients out of hospital," said Dr Thomas, lead author of the study.

The clinic has treated 372 patients in the five years since it opened.

In the first two years the clinic saved the hospital an estimated $3.46 million, the review found. The average cost of individual admissions was cut by more than half, from $25,883 to $9333.

Candice travels to the clinic twice a week.

"I used to get really scared in the lead up to treatment ... now it's just a relief to be stable," she said.

"I'm just really happy everything at the clinic runs smoothly and it's just a routine thing."

"She can get on with her life," Ms Murphy said. "She's an incredible girl and it's amazing to see her doing so well."

The story Pit stop clinic keeps vascular fistula patients off operating table first appeared on The Sydney Morning Herald.

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