Episode 35: How Percutaneous Procedures Can Help Patients Achieve Optimal Starts in Dialysis with Dr. Murat Sor
Optimal starts can result in fewer complications, reduce costs, and improve outcomes for patients. They are considered a key metric for success in many value-based care models. Dr. Murat Sor, Chief Medical Officer for Azura Vascular Care, joins Field Notes to explain how percutaneous procedures can result in optimal starts for patients.

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Brad Puffer: Welcome everyone to this episode of Field Notes. I'm Brad Puffer on the Medical Office Communications team at Fresenius Medical Care North America, and your host for this discussion today. Here we interview the experts, researchers, physicians, and caregivers who bring experience, compassion, and insight into the work we do every day. Optimal starts are generally defined as when a patient starts at home dialysis, receives a preemptive transplant or starts in-center hemodialysis with a permanent access. They can result in fewer complications, reduce costs, and improve outcomes for patients. That's why they're also a key metric for success in many value based care models. But optimal starts require catheter placements for peritoneal dialysis or a permanent fistula that can be done easily and quickly. So, what prevents every patient from receiving an optimal start to their dialysis? Here to discuss optimal starts is interventional radiologist and Chief Medical Officer of Azura Vascular Care, Dr. Murat Sor. Dr. Sor, welcome to Field Notes.

Dr. Murat Sor: Hi. Thank you for having me.

Brad Puffer: I started to define an optimal start, but how does the government define it and why is it so important?

Dr. Murat Sor: At least how we look at it from the vascular access and dialysis access point of view, it means that the patient starts with a permanent access, either a fistula graft or PD catheter, either in-center or at home. And the government incentivizes this because it's been shown in many studies that patients have better outcomes when they have an optimal start. They do better clinically, they have better quality of life, and they cost the system less.

Brad Puffer: Well, as Medical Director for Azura Vascular Care, which is a Fresenius Medical Care company, what is your mission and what is your goal at Azura?

Dr. Murat Sor: Well, actually, our mission is the same as Fresenius: to deliver superior care that improves the quality of life of every patient every day, setting the standard by which others in the health care industry are judged. For Azura, this means the highest quality dialysis to access care, timely vascular access and timely PD catheter placement and timely maintenance procedures. Our mission is to avoid hemodialysis catheters and make sure that we work in a coordinated fashion with our nephrology partners to get catheters out when they are in the patient.

Brad Puffer: And Dr. Sor, you're across the country, correct?

Dr. Murat Sor: Yep. We have 70 centers, and we're coast-to-coast.

Brad Puffer: Well, as the company continues to encourage and support more people choosing home dialysis, and I'm talking Fresenius Medical Care, there has been a lot of work done to educate patients earlier in their disease progression so they're ready to start dialysis at home. How do you think nephrologists can make that transition easier when it comes to having PD catheter placement ready to go, for example? What are the options?

Dr. Murat Sor: Well, as you mentioned, the most important step is these early conversations by the nephrologists, and then the nephrologist needs to refer their patients to a physician, a surgeon, or an interventionalist that is able to schedule a consult and a procedure with short wait times. For example, many of our centers do PD consults within the same day or next day, and some will even do it by telehealth. This allows for prompt consultation, discussion with the patient, and prompt scheduling for the actual procedure. Now, there are two main ways that PD catheters are placed that can be placed surgically or percutaneously. Percutaneous, which means through the skin, is the way that we do it at Azura. And it has several advantages when it comes to the earlier use of the catheter.

Brad Puffer: So, Dr. Sor, what are those advantages?

Dr. Murat Sor: First, these procedures can be done with conscious sedation and local anesthesia as opposed to general anesthesia, which is what they need when it's surgically placed. Since we're doing them with just sedation, these patients don't need cardiac clearance and that saves time, and it's often a barrier to get the patient scheduled. Second, patients are more likely to proceed with the scheduling of a procedure when they know that it's percutaneous or a minor procedure. Sometimes they get a little nervous about scheduling a full-on surgical procedure at the hospital. So, this also helps with scheduling and getting the patient’s buy-in. Also, when you're placing it percutaneously, since there's not a lot of other workup and scheduling things, we can get it scheduled within 24 to 48 hours after the initial consultation, especially if the patient is on any blood thinners or contrary indications. And lastly, percutaneously placed fistulas can be usually used within 24 or 48 hours in an urgent start situation with low volumes. So, given all these benefits and that they have outcomes that are pretty close to surgically placed PD catheters of greater than 90%, I think they're a home run for the patient.

Brad Puffer: There may be times when a percutaneous catheter is not appropriate. So just to give the whole the whole spectrum, when should doctors be careful about using a percutaneous catheter?

Dr. Murat Sor: Absolutely. There are some patients that are better candidates than others. So percutaneous PD catheters are placed with ultrasound and fluoroscopic guidance. And it's somewhat limited in patients that have very large body habitus or if they have previous abdominal surgery, they may have adhesions which when we're placing them percutaneously, we can't lysis these adhesions. So those would be the cases where I would often think of surgery as an option. But even in these patients with larger body habitus and previous abdominal surgery, it's still worth consulting an interventionalist to see what they think are the success rates. Because often even in these patient subcategories, we can be successful. And even if we're not successful, the patients can still go on to have the surgically placed catheter because our procedure is so minor and very low risk.

Brad Puffer: Well, we've been talking a lot about percutaneous PD catheters, but there are other newer methods of creating a fistula for hemodialysis, as well, correct? How has that technology evolved over the last decade?

Dr. Murat Sor: Percutaneous fistula creation was like the holy grail of minimally invasive dialysis access procedures when I was trained in the nineties. In the last several years, two technologies have really emerged to be the leaders in this field. One is called Wavelength, and one is called Ellipsys. Both of these technologies take advantage of a certain anatomy in the proximal forearm where the artery and the vein lie very close to each other, two millimeters or less. Now, the Wavelength catheter, or system, has two catheters; one goes in the artery, and one goes in the vein. And they're steered under X-ray guidance to a point where they're close to each other. They have magnets on it that align the two catheters together and then a radiofrequency energy beam, if I can say, is emitted between the two catheters, causing a split between the two vessels, and then a fistula is formed. The Ellipsys system is a little bit different. It's a single catheter system, and it's deployed under ultrasound guidance. And you go through what's called a perforator, or a connecting vein between the surface vessel and then the deep vein and the artery. And using ultrasound guidance, the wire and needle are placed through the perforator into the artery. The device is loaded, engaged, and a fistula is created. Both these systems are minimally invasive and can be done under local anesthesia and they leave no significant scars. These fistulas tend to have multiple outflows and often need additional endovascular maturation procedures before they can be used. But they are both highly successful in patients that have the right anatomy. They generally can be used in 60 to 90 days. Our experience is that about 40% to 50% of patients that present for a consultation are actually a candidate for percutaneous AVFs.

Brad Puffer: Well, it's great to know that the technology continues to evolve and is helping more patients. When you speak to other physicians, what do you say to convince them that they should consider percutaneous placements, whether it's PD or hemodialysis? Should this always be considered the first option for patients?

Dr. Murat Sor: You know, I think that's definitely a conversation that the nephrologist, the interventionalist, and the patient need to discuss because every patient is different. I'm definitely an advocate of these percutaneous procedures because they do have such high success rates, low risk, it can be done under local anesthesia and conscious sedation, and we can generally do them sooner than the traditional methods and they can be used sooner because of the coordination of care than the traditional methods. And as I mentioned before, if they're not successful, they don't prevent you from having a more traditional procedure done, an open procedure.

Brad Puffer: Are we seeing more people adopt these techniques, Dr. Sor? What are the biggest challenges to increase the percentage of percutaneous procedures being done, and what can we do to increase those number of placements?

Dr. Murat Sor: I think you see the barriers on two fronts. One is do we have enough interventionalists that are trained to actually do these procedures? And we've made a big effort at Azura to train up our physicians both on endovascular AVF and on percutaneous PD catheter. So, we have training programs, and we internally train our physicians on PD, and we get support from industry on the percutaneous. Having more people doing it, clearly, is going to have more opportunity for the patients to have these procedures done.

And then the next barrier is educating nephrologists and the patients. Since these are new technologies and new methods, people just aren't aware that they're available in their market. So, we do a lot of work with our nephrology partners to try to get the word out that these are an option and they're a great alternative to traditional surgery.

Brad Puffer: And how would you say these optimal starts having that placement ready to go at the start of dialysis impact a patient's potential treatment costs or outcomes? And how does this all correlate to value based models of care?

Dr. Murat Sor: Research is pretty clear that these people who start dialysis in a planned way with a permanent access have better early dialysis outcomes. We have improved quality life. There is lower cost to the health care system as compared to patients who have an unplanned dialysis start. The new CKCC or comprehensive kidney care contracting levels, as well as other value based models, are clearly trying to encourage these outcomes by paying more for these patients to have an optimal start, including having an optimal start as the most important quality measure within the CKCC models.

Brad Puffer: So, between the primary care physicians, the nephrologists, the interventionalists, and so on, how can a patient's care team work better together to increase this likelihood of an optimal start?

Dr. Murat Sor: These early conversations by the primary care and nephrology teams armed with the information they need to provide to patients about these less invasive, more convenient procedures would help. Patients often are going to hesitate to proceed because they're fearful of surgery and anesthesia. I believe that they'd be more amenable to scheduling these procedures if they knew that they were an option.

Brad Puffer: And Dr. Sor, do you think we'll see a real uptake in the number of percutaneous procedures being done? Will this continue to grow in frequency?

Dr. Murat Sor: We're seeing it right now in the organization. Incredible growth in the number of PD catheters and percutaneous fistulas that we're placing. So, without a doubt, as more interventionalists are trained to do these procedures and more nephrologists see the advantages of the procedures, their high success rates, low complications, and the timely placement, I think we're going to have more and more patients opting to do it this way.

Brad Puffer: Well, Dr. Sor, this has been really interesting. I learned a lot about vascular access and especially how it relates to optimal starts and why that's so important. I can't wait to see what happens over the next few years as we work to increase these number of optimal starts and our patients living with kidney failure. Thanks for joining us.

Dr. Murat Sor: Absolutely. Thanks for having me.

Brad Puffer: Well, to our audience, thank you for joining us. If you're new to the Field Notes podcast, you can download past episodes on the Apple Store or Google Play or right here at FMCNA.com. And while you're there, please subscribe to receive the very latest episodes as they happen. Until next time. I'm Brad Puffer, and you've been listening to Field Notes by Fresenius Medical Care. Take care, everyone.