For professionals
For professionals: referring vascular access cases
This page is for nephrologists, oncologists, haemodialysis nursing teams and other surgeons who follow patients with vascular access. Dr. Pedro Mellucci accepts referrals for creating, rescuing and treating access for haemodialysis and chemotherapy, including complex cases such as exhausted access and central venous disease. The referring team receives a report after the patient is seen, and follow-up is shared.
Which cases to refer
| Situation | Examples |
|---|---|
| First access | Advanced chronic kidney disease with dialysis expected; a patient on dialysis through a catheter who does not yet have a fistula |
| Fistula that is not maturing | A fistula more than 6 weeks old without adequate diameter, flow or depth for needling |
| Access dysfunction | Low flow, high venous pressure, recirculation, prolonged bleeding after needle removal, increasingly difficult needling |
| Fistula or graft thrombosis | Loss of thrill; rescue is generally attempted up to 14 days after occlusion, and the sooner the better |
| Central venous disease | Swelling of the limb, face or neck, collateral veins on the chest, history of multiple catheters |
| Fistula complications | Steal syndrome, aneurysms and pseudoaneurysms, high flow, infection |
| Exhausted access | Patients without usable peripheral veins, candidates for alternative routes such as the innominate vein, translumbar inferior vena cava or transhepatic access |
| Catheters | Insertion and exchange of tunnelled catheters, catheter dysfunction and infection, totally implantable ports for chemotherapy |
Situations that need same-day contact
- recent thrombosis of a fistula or graft;
- thin, shiny or broken skin over the fistula or an aneurysm, because of the risk of rupture;
- bleeding from the access that does not stop with pressure;
- hand ischaemia: rest pain, pallor, coldness, loss of sensation or ulcers;
- signs of access infection, with fever or discharge.
Contact can be made directly through the clinic's phone or WhatsApp, stating that the case is urgent.
What to send with the referral
A well-summarised case avoids repeated tests and allows the procedure to be planned at the first consultation.
- Clinical summary: cause of kidney disease or oncological diagnosis, time on dialysis, comorbidities and transplant prospects.
- Access history: previous fistulas, grafts and catheters: side, site, dates and reason for failure.
- Current access: type, time in use and the signs of dysfunction noted by the team (flow, venous pressure, bleeding, needling difficulty).
- Imaging: Doppler, fistulography or CT angiography, if available.
- Medicines: especially anticoagulants and antiplatelet drugs.
- Dialysis schedule: unit, days and shift, so that the procedure can be planned without missed sessions.
How it works
- Contact and case discussionThe referring team sends the summary and, when needed, the case is discussed between professionals before the consultation.
- ConsultationIn person, with clinical assessment and Doppler in the same visit, or online for patients from other cities, with planning done remotely.
- ProcedureAt one of the hospitals where Dr. Pedro Mellucci operates in Presidente Prudente or, when the patient's travel arrangements require it, in São Paulo or Campinas. For planned cases organised in advance, the in-person consultation and the procedure can take place on the same day.
- Handing backThe referring team receives a report with the procedure performed, care instructions and when the access can be used.
- Shared follow-upMaturation and follow-up can be handled by the local team, with an open channel for further referrals.
Patients travelling from other cities or countries will find guidance on travel, stay and transit dialysis in Patients from other cities and countries.
Lifelong access planning
The North American vascular access guideline (KDOQI 2019) proposes choosing the access within an end-stage kidney disease life-plan, rather than applying a single rule to everyone. Planning takes into account the available veins, the expected time on dialysis, the possibility of a transplant and the next access should the current one fail. Referring early, before the options run out, preserves veins and avoids unnecessary catheters.
Training for teams
The team also offers training sessions for haemodialysis and oncology teams and units. Contact can be made through the same clinic phone or WhatsApp. The site's patient guides cover each topic in depth.
Frequently asked questions
Can I discuss a case before referring the patient?
Yes. For complex cases, discussing the case between professionals first helps decide whether referral is needed and which tests to arrange. Introduce yourself as a health professional and tell the clinic that you would like to speak directly with Dr. Pedro Mellucci.
Does the patient miss dialysis sessions because of the procedure?
Generally not. The procedure is scheduled around the patient's dialysis day and shift. After rescue of a thrombosed fistula, it can, as a rule, be used at the next session.
Does the referring team continue to follow the patient?
Yes. The aim is to sort out the access and hand the patient back to their team, with a report and instructions, keeping an open channel for further referrals.
References
- Lok CE, Huber TS, Lee T, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020;75(4 Suppl 2):S1–S164. doi:10.1053/j.ajkd.2019.12.001
- Schmidli J, Widmer MK, Basile C, et al. Vascular Access: 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2018;55(6):757–818. doi:10.1016/j.ejvs.2018.02.001
About the author
Dr. Pedro Mellucci is a vascular surgeon in Presidente Prudente, Brazil, dedicated to vascular access for haemodialysis and chemotherapy: fistulas, grafts and catheters.
Meet Dr. Pedro Mellucci →