Friday, March 15, 2013

Thrombectomy or Thrombolysis?

It's time to provide an update on Mom due to some very recent activity. In today's episode we'll learn about yet another medical procedure, but first let's start with the beginning of March. The dialysis session on Friday, March 1 went well. They still haven't started the buttonhole technique, but the plan now is to start it later this month after Mom gets back from a trip to Austin and the tech who creates the buttonholes gets back from vacation. It will be nice once that is done since the insertion of the needles is really painful.

Speaking of pain, Mom learned that they can give her a prescription for some Lidocaine cream to apply to her arm before a dialysis session. That will numb the skin a little and thereby reduce the pain when the needles are inserted. It would have been nice to know about that a little sooner.

Toward the end of the dialysis session on Monday, March 4, Mom started having a lot of pain in her arm due to one of the needles. Normally the pain doesn't last once they get them inserted and get dialysis started, but maybe she moved a little to make this one hurt. In any case, the pain was so bad that she called the tech over and said she couldn't continue because she was in so much pain.

On Wednesday, March 6 the tech got Mom started on dialysis and then looked at the machine and said, "Uh oh," which is just what you don't want to hear when your circulatory system is connected to a machine. Mom's blood was going into the machine fine, but it was clogging the machine on the way out. The tech had to clean out the machine, throw a bunch of stuff away, and start over. Fortunately Mom did fine after the restart.

Mom and I did not attend the local amyloidosis support group meeting on Saturday, March 9. She was in Austin and I was traveling to North Carolina.

Since Mom was in Austin she had a couple of dialysis sessions there. The one on Friday, March 8 went great, but on Monday they had an issue with the machine clotting again.

There seem to be a lot of issues with clotting lately, which isn't a total surprise since Mom isn't taking either of the two anticoagulants typically given to patients on dialysis. (That drama unfolded late last year and is covered in the January 30, 2013 post.) So it should come as no surprise that we eventually had a slightly more serious clotting issue.

On Wednesday, March 13, the dialysis machine was clotting frequently and they were having a lot of difficulty with clotting in the blood vessels of Mom's arm as well. They stopped dialysis early and scheduled her to go to Plano Vascular Center the next day for a procedure to clear the clots in her arm and then have dialysis at the center next door. I believe the procedure is either thrombectomy or thrombolysis, which is described in the "How does the procedure work?" section on this page: One procedure uses medication to dissolve the clot and the other one uses a mechanical device.

On Thursday, March 14 my sister Laura took Mom to the appointment at Plano Vascular Center. The doctor there said that she didn't need a thrombectomy or thrombolysis because there was no sign of the fistula clotting. He did, however, perform another balloon angioplasty, this time going a little higher than the most recent one on February 26. So this is the third angioplasty Mom has had on her fistula. They had a little trouble with the needles getting dialysis started, but they got it done and she was fine that night.

On Friday, March 15, she was supposed to have her regularly scheduled Friday dialysis session but they were having so much trouble getting the needles in that she told them to stop and she wouldn't have dialysis today since she had it yesterday. That would mean no dialysis between Thursday and Monday. The nephrologist came by later and said that was not a good idea because her potassium level could get way off going so long without dialysis. Since they are having so much trouble with the fistula he sent her back to Plano Vascular Center where she had another catheter inserted. This one is on her left side instead of right, and it's in her jugular vein so it's higher up. So I guess we're dealing with a permacath once again. Yay.

Here's what the doctor at Plano Vascular Center told Mom and how he recommends she proceed. Since her arm is so badly bruised from all of the attempted needle sticks, he thinks they haven't actually been getting blood just from the fistula but also (or in some cases only) from the bruises (hematomas). That's why they thought her fistula was clotting at the dialysis clinic. He checked her fistula and said it's perfectly fine and actually very strong (good blood flow).

Going forward, he wants her to use just the catheter for dialysis for the next week or two, allowing her fistula and arm to heal. Then hopefully she can have one of the more experienced techs at the dialysis clinic try to access the fistula again. If they still have trouble then she may need to have a procedure where the blood vessels of the fistula are brought closer to the surface of the skin.

We were quite concerned on Wednesday that we would need to have some serious discussions with Mom's hematologist about putting her on some sort of anticoagulant, but now it looks like there may be a different explanation for the clotting issues they are experiencing during her dialysis sessions. Hopefully there will be some good news to report in two to three weeks.

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