AV FISTULA SURGERY FOR HEMODIALYSIS

A fistula used for hemodialysis is a direct connection of an artery to a vein. Once the fistula is created it is a natural part of the body. This is the preferred type of access because once the fistula properly matures and gets bigger and stronger; it provides an access with good blood flow that can last for decades. After the fistula is surgically created, it can take weeks to months before the fistula matures and is ready to be used for hemodialysis. People with kidney disease can do exercises including squeezing a rubber ball to strengthen the fistula before use.

The multidisciplinary management of dialysis access coordinated among vascular surgeons and nephrologists has proven extremely effective in prolonging the success of fistulas and decreasing the morbidity and mortality of patients with Kidney failure.

Schematic representation of coonection between AV fistulas and Dialysis machine

Hemodialysis fistula has a very high failure rate. It is a very delicate procedure and needs fine instruments and is done using a microscope,One in four fistulas fail in the very first month if not done properly. Fistulas if not done by experienced hands can lead to number of complications including limb compromise.

Schematic representation of coonection between AV fistulas and Dialysis machine

Fistula gone wrong, (Performed in an outside center),presented to us with enormous limb swelling and severe pain

Fistula Complication- Gangrene Thumb

Hence its imperative that fistulas be performed by a vascular surgeon or experienced hands.

Indications

Less than 15% of dialysis fistulas remain patent and can function without problems during the entire period of a patient’s dependence on hemodialysis. The mean problem-free functioning rate  after creation of native fistulas is approximately 3 years, whereas prosthetic polytetrafluoroethylene (PTFE) grafts last 1-2 years before indications of failure or thrombosis are noted. After multiple interventions to treat underlying stenosis and thrombosis, the long-term secondary patency rates for native fistulas are reportedly 7 years for fistulas in the forearm and 3-5 years for fistulas in the upper arm; prosthetic grafts remain patent for up to 2 years.

Causes of dialysis fistula failures:

Various causes include Faulty technique, surgical and iatrogenic trauma, such as repeated venipunctures. Stenoses along the venous outflow and in intragraft locations (for prosthetic PTFE grafts) are also common and require appropriate treatment.

Once kidney function goes below 10 to 15 ml,  dialysis treatments or a kidney transplant are necessary to sustain life.

Hemodialysis cleans blood by removing it from the body and passing it through a dialyzer, or artificial kidney. The dialyzer is a filter with two parts: one for blood and another for dialysis fluid, called dialysate. The filter between these two parts has very small pores, allowing some tiny particles to pass through. The particles that are filtered include the toxins that need to be removed from the body such as urea, creatinine and potassium, while larger blood cells and protein the body needs cannot pass through. The filtered blood is then returned to the body.

The process of removing blood from the body, filtering it and returning it takes time. Hemodialysis treatment usually takes three to five hours and is repeated three times a week

Fistula — the gold standard access

The National Kidney Foundation (NKF), Centers for Medicare and Medicaid Services (CMS), DaVita Patient Citizens (DPC) and other organizations and experts generally agree that fistulas are the best type of vascular access. Low rates of complications, clotting and infection all contribute to the fistula’s reputation as the “gold standard” of vascular access.

Dialysis experts also generally agree that the safest and longest lasting of the access types is the AV fistula. Because a fistula is made by connecting a vein to an artery, the vein becomes bigger allowing for increased blood flow. The fistula is created from natural parts of the body and can be repeatedly “stuck” to perform hemodialysis treatments.

A fistula is the “gold standard” because:

  • It has a lower risk of infection than grafts or catheters
  • It has a lower tendency to clot than grafts or catheters
  • It allows for greater blood flow, increasing the effectiveness of hemodialysis as well as reducing treatment time
  • It stays functional for longer than other access types; in some cases a well-formed fistula can last for decades
  • Fistulas are usually less expensive to maintain than synthetic accesses

While the AV fistula is the preferred access, there are some people who are unable to have a fistula. If the vascular system is greatly compromised, a fistula may not be attempted. Some people have had fistulas surgically created, but the fistula never matured; therefore, could not be used. Some of the drawbacks of fistulas are:

  • A bulge at the access site that some people feel is unattractive
  • Taking several months to mature
  • Sometimes never maturing at all

“Fistula First” initiative

The Centers for Medicare & Medicaid (CMS) and members of the renal community have come together to start the “Fistula First” initiative (National Vascular Access Improvement Initiative) with the goal of expanding the number of patients with fistulas, as opposed to catheters or grafts.

“When I entered practice in the mid-1970s there were fewer than 10,000 end stage renal disease (ESRD) patients receiving hemodialysis,” said Lawrence Spergel, an expert on ERSD who spoke with the Institute for Healthcare Improvement (IHI). “That number has increased to almost 300,000 patients today. In every community, there are patients whose lives depend on dialysis, which, in turn, depends on a well-functioning vascular access. This [ESRD] population will continue to grow because more and more of these patients are living longer. However, for hemodialysis patients to live long and productive lives, optimal vascular access and care are required.”

Further, synthetic accesses account for an estimated $1 billion in complications costs for Medicare, according to IHI. The CMS has put that number at $1.5 billion.

According to Fistula First, even people with other access types are still good candidates for fistulas. Studies have shown that when patients who have exhausted permanent access sites are re-evaluated and undergo vessel mapping, at least two-thirds are found to be candidates for an AV fistula.

To date, the initiative has overreached its goal of 40 percent of prevalent patients with fistulas. For 2010 the bar has been raised, with the hope being that 50 percent of all new people on hemodialysis will have a fistula and 66 percent of continued patients will use a fistula.

Fistula care

Cleanliness

Cleanliness is one way someone on hemodialysis can keep their fistula uninfected. Keep an eye out for infections, which can often be detected when there is pain, tenderness, swelling or redness around the access area. If you notice fever, contact your health care professional. Your doctor may prescribe antibiotics for an infection, which should likely go away easily with early diagnosis.

Unrestricted blood flow

Any restriction of blood flow can cause clotting. Here are some tips to help keep blood flowing without restriction:

  • Avoid tight clothing or jewelry that could put pressure on your access area
  • Do not carry bags, purses or any type of heavy item over your access area
  • Don’t let anyone put a blood pressure cuff on your access arm — have your blood pressure taken from your non-access arm
  • Request that blood being drawn is taken from your non-access arm
  • Don’t sleep with your access arm under your head or pillow
  • Check the pulse in your access daily

The vibration of blood going through your arm is called the “thrill.” You should check this several times a day. If the “thrill” changes or stops a blood clot may have formed. By immediately contacting your doctor or dialysis health care team the clot may be quickly dissolved or removed.

Using a stethoscope, or even putting your ear to the access, you can hear the sound of blood flowing through your access. This sound is called the “bruit.” If the sound gains in pitch and sounds like a whistle, your blood vessels could be tightening (called stenosis). If the tightening becomes too severe, blood flow could be cut off completely.

During dialysis, your pre-pump arterial pressure is monitored. This will tell you how difficult it is for the blood pump to draw blood from your access. If the number is negative, there could be a restriction of blood flow through your fistula.