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Av Fistula Treatment
As your nephrologist (or renal physician or kidney disease specialist) has already explained to you, you have a condition called end-stage chronic renal failure, which means that your kidneys have suffered permanent damage so that they cannot clear your blood efficiently from certain toxic substances circulating in it. Your kidney function will be replaced by the dialysis machine (artificial kidney) to which you will be connected 3 times a week.
This connection is performed via two fine and flexible catheters, which will be introduced in your vein through the skin each time. The first catheter (“artery”) will direct your blood to the machine, where it will be filtered. The blood, cleaner now, will be returned to your circulation via the second catheter (“vein”) and through the other puncture site.
The angioaccess (or vascular access) procedures, namely the construction of a fistula or a graft implantation, aim at creating the possibility for the Dialysis Unit staff to have easy access to a vein of yours, which should lie just under the skin and maintain a high blood flow, so that it can be easily and safely punctured.
The vascular surgeon will try to identify a suitable superficial vein of an upper limb (forearm or arm) and create high blood flow in it by connecting it with sutures to a nearby artery. This direct arterio-venous communication is called a fistula.
However, if your veins are too thin or scarred by previous punctures for blood taking, IV drug administration etc, the vascular surgeon is very likely to have to implant a graft (plastic tube) under you skin with its one end connected to an artery and the other end to a vein of yours so that a high blood flow is maintained in it.
If your upper limbs are thought to be unsuitable for such a procedure, it can be performed in a thigh or very rarely in other areas of your body.
Apart from a suitable vein, you need to have a suitable artery for sewing without much calcification on its wall. At the same time, the overal arterial circulation to your limb has to be normal without any arterial narrowings, otherwise there is risk for reduction of the blood supply to the limb (arterial steal syndrome) which may cause gangrene of the digits.
The vascular surgeon also will be reluctant to implant a graft if there is an active infection anywhere in your body, because of the risk of graft infection. If graft infection occurs, the graft will have to be removed.
Before selecting the operation site, the vascular surgeon will examine your limbs and may organize a duplex scan for mapping of your arm veins, and rarely a venogram or a digital subtractive arteriogram. You will also be instructed whether you need to discontinue any drug which could increase the risk for bleeding.
You will usually be admitted the morning of the day of the operation. You will be asked to have starved for at least 6 hours before the operation, but you may be allowed to have a light breakfast very early in the morning if your operation is scheduled in the afternoon.
When coming into the hospital, it will be very useful to bring along a medical note by your nephrologist stating your medications, any known allergies you may have and any recent blood test results (including your viral antigen profile), chest x-ray or cardiology investigations. You will be asked to sign a form confirming that you understand why the procedure needs to be performed, the risks of the procedure and that you agree to the surgery.
The operation is usually performed under local anaesthetic, however, the vascular surgeon may ask the anaesthetist to give you light sedation or rarely general anaesthesia.
The vascular surgeon will try to construct the fistula with an incision using the forearm of your non-dominant upper limb. For example, if you are left handed, your physician will place the fistula in your right arm, if possible. To perform the operation, your surgeon joins a suitable vein under the skin to an artery nearby, divides your vein and sews it to an opening made in the side of the artery. As a result, the blood flows down the arteries into the hand, as usual, and also some of this faster moving blood flows into the veins that lead back to your heart. The blood that normally traveled in your divided vein goes back to the heart through other veins, and there is usually plenty of blood remaining in your artery to supply your hand. The vein (now called the fistula) will gradually start to “mature” (i.e. dilate and its wall will become harder), so that in 5-6 weeks it should be suitable for inserting the big needles in it. If it doesn’t mature in a reasonable period, e.g. 3 months, you may need a new operation.
If you cannot receive a fistula because the vein is too thin or blocked, your physician may construct a graft using a tube of man-made, plastic material. Your surgeon sews one end of the graft to one of your veins and the other end to an artery. The graft material will be placed straight or will form a loop under the skin either in your lower arm, upper arm, or less commonly in your leg. Grafts can usually be punctured within 2 weeks.
It is generally preferable to have a fistula than a graft, because it resists to infections and has a better long-term patency, however, if your veins are not suitable, a graft is an excellent alternative.
- After the operation, you should initially keep the access area raised above your heart to reduce swelling and pain. Your surgeon may recommend an over-the-counter painkiller to relieve pain, if necessary
- Some pain or swelling are frequent and you should not worry as long as they improve. However, if they get worse, you must mention it to your physician immediately, as you should do in case of fever or if the wound leaks or bleeds
- Keep the wound dry for 4-5 days. If you have non-absorbable stitches, these will need to be removed usually in 7-10 days
- Avoid lifting more than about 8 kg or other activities that stress or compress the access area, such as digging
- You should perform exercises to grow and strengthen your fistula, after the pain from the surgery decreases, to make dialysis possible faster and easier. Your physician may recommend squeezing a soft object using the hand on the arm in which the fistula was placed
- You may initially feel some coolness or numbness in the hand with the fistula. These sensations usually go away in a few weeks as your circulation compensates for the fistula. However, if these sensations are severe or do not disappear, tell your physician as soon as possible, because the fistula may be causing too much blood to flow away from your hand, a condition physicians call an “ischaemic steal”
- Grafts mature faster than fistulae, however they have some disadvantages: they are more likely to get infected and tend to last less than fistulae. If you care properly for your graft, however, you can help it last for many years
- Evidently, until the access portal is ready, a catheter in a central vein (usually in your neck) may have to be used for dialysis
Potential complications with dialysis access procedures include:
- bleeding
- infection
- stenosis (narrowing) or thrombosis (occlusion) of the access
- limb swelling
- neuropathy
- “ischaemic steal syndrome” discussed above
- aneurysm formation
Protecting your vascular access is crucial for you!
- Check several times each day that it is functioning. You must be able to feel a vibration called a “thrill”. Your physician or Dialysis Unit staff will be able to show you how to do this
- Monitor for swelling, redness or bleeding after dialysis
- Keep the access site clean
- Do not carry heavy things with the arm which has the access
- Do not sleep on the side of the access
- Do not wear any clothes or jewellery that bind that arm
- Do not let anyone measure your blood pressure on this arm, draw blood or give injections into your fistula or graft
- Do not put any creams or lotions over the site of your fistula or graft – with the exception of Emla cream as a local anaesthetic 1-5 hours before your dialysis
- How to choose the access that is best for you
- About the pros and cons of the different types of access
- Why your access is important to getting the most from your hemodialysis treatment
- How to care for your access
- How to keep your access working well
Yes. Three different types of access can be placed for hemodialysis. They are called a fistula, a graft, and a catheter. Your doctor should teach you about the pros and cons of each one. Your doctor should refer you to a special surgeon with hemodialysis access experience at least six months before you need to start treatment. This surgeon will evaluate you and help you choose the type of access that is best for you. Once your doctor tells you that you will need dialysis, you should protect the arm where the surgery will be done. Don’t allow anyone to draw blood or give you an injection in this arm. Also, never let anyone use a cuff to take your blood pressure from this arm. You should wear a medical alert bracelet to inform hospital staff about your arm.
An AV (artery-vein) fistula is the best choice for hemodialysis. It is preferred because it usually lasts longer and has fewer problems like clotting and infections. A fistula should be placed several months before you need to start dialysis. This allows the fistula enough time to be ready for when you need treatment.
Minor surgery is needed to create the fistula. It is made by connecting a vein to a nearby artery, usually in your arm. This creates a large blood vessel that has a fast flow of blood. Your wrist or elbow is the preferred location for your fistula. A fistula will usually last for many years. A fistula usually takes one to four months to “mature” or enlarge before it can be used. If you are already receiving hemodialysis using an AV graft or catheter, ask your doctor about the benefits of a fistula.
An AV (arteryvein) graft is the second choice for an access. Minor surgery is done using an artificial tube between a vein and a nearby artery. An AV graft is usually put inside the bend of your arm or in your upper arm. Sometimes, it may be placed in your leg or chest wall. The AV graft generally needs to be in place at least two weeks after surgery before it can be used.
A catheter is most often used for a temporary access. For example, it is sometimes used for a short time in people who get an AV fistula and need to start dialysis before the fistula is ready. Once the fistula is “mature,” the catheter will be removed.
Sometimes a catheter is used over a long period of time because a fistula or graft is not possible.
Catheters are made of soft plastic tubing. There are two parts, one for removing your blood and the other for returning the cleaned blood to your body.
A catheter is placed only when you need to start dialysis. It is put in a large vein, usually in your neck but sometimes in your upper chest. Catheters have more problems (like clotting and infections) than fistulas or grafts. They may not have enough blood flow for good dialysis treatment.
- Lasts longer
- Not prone to infection
- Provides excellent blood flow once it is ready to use
- Less likely to develop blood clots and become blocked
- You can take showers once the access heals after surgery.
- Needs to mature one to four months before it can be used
- Needles are inserted to connect to the dialysis machine.
- Can be used right away
- No needles are needed to connect to the machine.
- Usually a temporary access
- Most prone to infection
- May not have the blood flow needed for enough dialysis
- Blood clots can form that block the flow of blood through your catheter.
- You need to wear a protective cover for your catheter to take a shower.
- Can cause narrowing of major blood vessels
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Cons:
- Keep it dry; once it is healed you can take showers.
- Watch for bleeding.
- Take all medicine that is prescribed.
- Get enough rest.
- Call your doctor if you:
- Notice redness, pain, swelling, or a feeling of warmth at the access site
- Feel short of breath
- Have flu-like symptoms
- Have a temperature of 99 degrees or higher
- Keep your arm straight and elevated (above your heart) while the access is healing.
- Ask the nurse at the hospital to show you how to check your access at home for a vibration (called a “thrill”) or for a sound (called a “bruit” pronounced “brew-ee”).
- Ask your doctor when you can start doing exercises, such as squeezing a rubber ball, to help your access mature and be ready to use.
- Your doctor should check your access to make sure it is maturing properly.
- Keep it dry; once it is healed you can take showers.
- Watch for bleeding.
- Take all medicine prescribed for you.
- Get enough rest.
- Call your doctor if you:
- Notice redness, pain, swelling, or a feeling of warmth at the access site
- Feel short of breath
- Have flu-like symptoms
- Have a temperature of 99 degrees or higher
- Keep your arm straight and elevated (above your heart) while the access is healing.
- Ask the nurse at the hospital to show you how to check your access at home for a vibration (called a “thrill”) or for a sound called a “bruit” pronounced “brew-ee”).
- Keep the dressing dry; once healed, you can take showers using a protective covering over your catheter.
- Watch for bleeding.
- Take all medicine prescribed for you.
- Get enough rest.
- Call your doctor if you:
- Notice redness, pain, swelling, or a feeling of warmth at the access site
- Feel short of breath
- Have flu-like symptoms
- Have a temperature of 99 degrees or higher
- Improve your overall health
- Help you live longer
- Improve your quality of life
- Keep you out of the hospital
Yes. They should check your access at least once a month. Special tests should also be done. These may include:
- Measuring flow in your access
- Measuring pressure in your access
- An imaging test called duplex ultrasound
- Ask your dialysis care team to teach you about preventing infection and keeping your fistula or graft working well.
- Wash your access site every day with an antibacterial soap. Ask your dialysis care team to recommend a good soap to use.
- Wash your access site before every dialysis treatment. Your dialysis center has hand washing sinks and antibacterial soap.
- Do not scratch your access. Your fingernails could be a source of infection.
- Your nurse or technician should clean your access site with an antiseptic before putting the needles in. Do not touch your access area after it has been disinfected.
- Your nurse or technician should wear a surgical mask, a face shield, and clean gloves when working near your access.
- Avoid coughing or sneezing on your access site during treatment.
- Always wear a clean glove or use a clean gauze pad if you are holding your own access site after the needles are pulled.
- Apply only gentle pressure to stop bleeding after the needles are removed. Press only where the needle was and just below. Never press above where the needle was.
- Call your dialysis care team at once if the area of the access is sore, swollen, red, or feels hot. This could be a sign of infection.
- Do not let anyone measure your blood pressure on your access arm. Your other arm should be used instead.
- Do not let anyone take blood from your access arm when you are not on dialysis.
- If the vibration (thrill) or sound (bruit) of your access is absent or seems different, call your dialysis care team at once. This could mean the access is not working well.
- Ask your dialysis care team how to make your needle sticks as comfortable as possible. They can use different sites for the needles during each dialysis. Or, if you have a fistula, a “button hole” technique can be used. This uses the same site for each dialysis, and may be less painful.
- Ask your dialysis care team to teach you how to prevent infections and keep your catheter working well.
- Be sure your catheter has a clean, dry dressing during and after every dialysis. Make sure your nurse or technician checks your catheter for signs of infection at every dialysis session.
- Make sure you wear a surgical mask when you are being connected to or disconnected from the dialysis machine.
- Make sure your nurse or technician wears a surgical mask, face shield, and clean gloves when working near your catheter.
- Use a protective cover for your catheter to take a shower. Ask your dialysis care team how to get one of these covers.
- Ask your nurse or technician to teach you or your family how to change the dressing.
- Keep extra dressing supplies at home in case you need to replace your dressing.
- Call your dialysis care team right away if your catheter cuff is showing.
Infection
Warning Signs: Redness, swelling, soreness, and/or a feeling of warmth around your access site; fever, chills, and/or achy feeling.
Steps to Take: Call your doctor or dialysis care team at once.
You’ll need to take antibiotic medicine prescribed by your doctor.
Clotting or Poor Blood Flow in Your Access
Warning Signs: Absence of the vibration (thrill) or sound (bruit) at your fistula or graft site; swelling of your arm; lower skin temperature around the access site; a decrease in your delivered dose of dialysis (Kt/V or URR); or changes in other lab values.
Steps to Take: Call your doctor or dialysis center. Keep a record of your Kt/V or URR and other labs. Speak to your dialysis care team when there are changes.
Bleeding From Your Access
Warning Signs: Bleeding from a fistula or graft that lasts more than 20 minutes after your dialysis
treatment is over.
Any bleeding from a catheter site or catheter tube.
Steps to Take: For bleeding from a fistula or graft, gently press your access with a clean gauze pad to stop
the blood; if bleeding lasts more than 20 minutes, call your doctor or dialysis center at once.
For bleeding from a catheter site or tube, call your doctor or dialysis center at once, or go to the emergency room at your local hospital.
Decreased Circulation in Your Access Arm
Warning Signs: Feelings of numbness, tingling, coldness or weakness in your arm; blue fingers or sores at the tips of your fingers.
Steps to Take: Call your doctor or dialysis center right away (this must be treated at once to prevent nerve
damage in your access arm).
- Keeping your access working well will help you get the most from hemodialysis, and help you feel your best.
- If your access is not working well, it can decrease the amount of dialysis you receive. This will affect your overall health and how long you live on dialysis.
- A fistula is the preferred type of access. If you are already receiving hemodialysis and you do not have a fistula, ask your doctor or dialysis care team if you are a candidate for a fistula.
- Make sure your dialysis care team checks your access often. They should do some special tests to make sure it is working well.
- Do not let anyone measure your blood pressure on your access arm, or take blood from your access arm when you are not getting dialysis. Your other arm should be used to measure blood pressure and do blood tests.
- Ask your dialysis care team to teach you the steps for good access care to prevent infection and keep your access working well.
- Know the warning signs for problems with your access.
- Track your important test results, such as your Kt/V and your URR.
- Ask your dialysis care team if you have any questions about your access or any other aspects of your hemodialysis care.