“If I had not been an interventional radiologist, I would have been a nephrologist.” John Aruny’s abiding interest in kidney disease treatment and a long career in interventional radiology (IR) have seen him assume leading roles in the field. He was president of the Vascular Access Society of the Americas (VASA) from 2020–2022 and, until 2018, co-director of Vascular and Interventional Radiology at Yale New Haven Hospital in New Haven, USA. Speaking at the 2022 Vascular Access Society of Britain and Ireland (VASBI) annual scientific meeting (29–30 September, Glasgow, UK), Aruny—who is currently an interventional radiologist at the Dialysis Access Institute in Orangeburg, USA—tells Renal Interventions about dialysis access care being a model of multidisciplinary working; the maxims he lives by; sailing on a boat called Sonic Boom; and why he knows the names of all the Disney princesses.
What sparked your initial interest in medicine, and IR?
I would probably have been a nephrologist if I had not been an interventional radiologist—there are probably very few radiologists who are interested in single-nephron glomerular filtration rate (GFR), or middle molecules and how they respond, but keeping up to date with developments in nephrology is a passion for me. It was a longstanding family friendship with a nephrologist, who is now one of my son’s godfathers, that got me interested in renal disease. I started out as a nuclear medicine technologist and attended a lecture about embolisation of bleeding oesophageal varices. That experience really impressed me; I thought: “Wow, this is something that has sort of inspired me.” I went to medical school to be an interventional radiologist after that experience.
How did you develop a programme in which IR was integral to dialysis access?
When we first developed the dialysis access programme, IR was responsible for 85% of the dialysis access service. The model was a very simple one: we never said no. We always communicated well within the practice; we went to visit the dialysis centres and set up good relationships. We set up an access hotline so that they could reach us anytime. This addressed the problem that, although dialysis access units knew we were doing good work, they found it hard to book us. With this relatively simple fix we assured them we would do the booking and get the procedure done as soon as possible—usually on the same day. I had an insight into the economics of a dialysis unit and that helped offer a service that was appreciated, and that is how the practice grew.
There was an interesting talk about identifying research priorities in vascular access at the VASBI meeting. Did these reflect your top three priorities?
I actually took a lot of notes during the research priorities talk. The thing is, since the 1970s, we are still stretching with balloons and still pushing clot out. We really have not gotten to the underlying physiology, and I think the research questions we pursue should be: How do mature fistulas mature? What is the best way to accelerate their maturation and identify patients early on that will go on to have fistulas that do not mature? Maybe they should get grafts instead to minimise catheter contact time. Cardiologists, for instance, have a suitcase full of drugs to tackle underlying physiology. The second aspect I would look at is the venous anastomosis of the graft, or where the graft might fail and how to prevent that. So, the question really is: How can we adjust our treatment to individualise it to a particular patient when they get into trouble? The third thing is central vein stenosis—how do you prevent central vein occlusion and better treat it when it occurs?
What are the most disruptive ideas and technologies in dialysis access you have encountered in your career?
The idea that endovascular procedures could be as successful as open procedures was a major idea shift. With regard to technology, the first is the covered stent, because it changed the whole scope of practice. One, it allowed the treatment of the access to extend beyond the surgeon, and surgery, to the radiologist and the nephrologist. The fear was always, ‘what if I rupture the vein? I will have to call the surgeon’, and you do not have to do that anymore. Now, you have a covered stent in place across that area and basically take care of your own complication. It also changed the patency, certainly of the venous anastomosis in grafts, so this was definitely a disruptive technology. It remains to be seen whether drug-eluting balloons are going to be as disruptive in the dialysis space; I think we still have work to do.
As immediate past president of VASA, which of the society’s activities are you currently excited about?
We have talked about developing an educational video for patients. There are a lot of patients that feel that they were not offered information about the different options that were open to them; they were shunted by their nephrologists into haemodialysis or peritoneal dialysis, and maybe did not know what it was going to involve, with needle punctures, for instance. We would like to put together a professionally made video that we could distribute to nephrologists so that patients will have a background on what to expect with each of these modalities. Then, when they go in to talk to their doctor, they will have an idea of what questions to ask. Done right, I think that would be a huge contribution.
What is holding home dialysis back, in your view?
There are several obstacles, particularly in large cities where space is a constraint. If you live in a rural area, you probably have a garage or an extra room to store the cartons of fluids and bottles and all the tubing. In cities, such as Manhattan, in studio apartments, patients simply do not have the space to do so. Also, there is the social aspect of going to dialysis to consider. When patients are on haemodialysis, they sit there for hours, and they talk to each other about their problems or home life. It is almost a social club, so financial planners should consider that—the sociopsychological benefits of being on dialysis. There is also a real shortage of quality dialysis technicians who believe that dialysis patients will not find it hard to learn how to cannulate their own access. So, how that all translates to ‘Total Home’ remains to be seen.
Given they are seeing patients with kidney disease in a very small snapshot in time, what should interventionists always be aware of?
If you are a patient with myocardial infarction, your treatment plan is very well established. It is pretty straightforward. In dialysis access, there is a lot of regional variation and individual variation, so I think that the person taking care of these patients really has to keep the patient’s wellbeing foremost in their mind. Then, understand that it is a difficult life to be a patient on dialysis, tied to this machine for three days a week, often for hours at a time. Outside of this, in order to do the right thing for patients and achieve good outcomes, I think we really need to understand that this is a complex field, and it needs to be elevated. Training needs to be augmented after residency to learn the algorithms, and when to do what and how to do it best. And, it is often just as important to know when not to do something. John Ross, my boss, says 80% of successful intervention is judgement and 20% technical ability; I probably favour more of a 50/50 split.
You make the point that vascular access is the perfect Petri dish to show the value of multidisciplinary collaboration—could you expand on this?
In the vascular access space, there is a real recognition that ‘multidisciplinary’ is the way to go. This idea has really taken hold and maybe other groups can learn from us. To be a good interventionist or percutaneous/endovascular specialist, you need to understand when surgery is the right option to go with for the good of the patient. While we can do a lot of things, there are some things we should not be doing; procedures that are just not appropriate or in the best interests of the patient. There is currently a big push in IR towards interventional oncology—IR has made oncology a new frontier. I would like to make the point that you will probably save more lives doing dialysis access interventions than if you treat all the liver cancers and renal cancers you can find. So, if you are really interested in saving lives and prolonging life, then vascular access offers a great option. It can be lucrative, both financially as well as offering tremendous personal satisfaction.
Could you describe a central vein occlusion case that has stayed with you over the years?
It is often a similar scenario in many different patients who come in with an access and an arm that is very swollen. They initially arrive in a sweatshirt, as they cannot fit into a regular shirt because one arm is so much bigger than the other, and they have central vein occlusion. So, we have an access on the same side and on the other side we have a central vein occlusion. They are naturally hesitant to give up their functioning access, so we will go and open up two central veins to recanalise them with angioplasty and, most likely, with stent graft placement. Within a week, their arm is back to three quarters of what it normally should be, but they are now coming in wearing a shirt. And they are all really grateful for what you have done for them. That is the greatest reward of doing the other central veins, because a lot of physicians do not—it is tough work, and it takes a little bit of daring and planning. But it is kind of our specialty to take care of these folks, often even when recanalisation has failed at other centres, and the patients are all very grateful when it gets resolved.
Do you have a go-to phrase that you use maybe too many times at work?
I have a pretty long list of all the things that I say, but very few are shareable! One is: You know, I am a technologist, I can do what you do. Another is: Live your life knowing there is someone who wants to do your job, will do it better than you and probably for less money. So, I try to live my life along that idea.
What are your interests outside of medicine?
My wife and I have been married for 42 years and have four children. One is a chef, another an artist, our third is a businesswoman and our fourth runs a business of trivia clubs, which is why I know the names of all the Disney princesses. I enjoy sailing and sailboat racing (on a sailboat named Sonic Boom). I also collect stamps, having inherited from my father and grandfather a collection with about 50 first-day covers, which are envelopes that are embossed with graphics or pictures of something related to the stamp that was issued. All of these people and activities keep me pretty busy.
- 2018–present: Interventional radiologist, Dialysis Access Institute (Orangeburg, USA)
- Up to 2018: Co-director, Vascular and Interventional Radiology, Yale University School of Medicine (New Haven, USA)
- 1999–2018: Diagnostic radiologist, and vascular and interventional radiologist, Yale University School of Medicine (New Haven, USA)
- Fellowship in Cardiovascular and Interventional Radiology, Brigham and Woman’s Hospital/ Harvard Medical School (Boston, USA)
- Residency in Diagnostic Radiology, New York Medical College (Valhalla, USA)
- Internship in Internal Medicine, Booth Memorial Medical Center/New York University (Flushing, USA)
- 2020–2022: VASA president
- 2010–2014: America’s Top Doctors, Castle Connolly
- 2009: Inaugural Shari Ullman Gold Medal Lecturer Award, AVIR
- Principal investigator, FLEX Arteriovenous Access Registry