An arteriovenous (AV) fistula if formed by joining a superficial vein (just underneath the skin) to an artery, most commonly in the non-dominant arm. This creates a high-flow of blood through the vein, which usually after a period of 4 to 6 weeks, becomes suitable to access for haemodyalisis in patients with renal failure.
Common types of AV fistulas include:
- Radiocephalic fistula - joining the cephalic vein to the radial artery (just above the wrist)
- Brachiocephalic fistula (see Figure 1) - joining the cephalic vein to the brachial artery (at the elbow crease)
- Brachiobasilic fistula - joining the basilic vein to the brachial artery (at the elbow crease). This is often combined with simultaneous mobilisation and re-tunnelling of the basilic vein (transposition) so that it is in a favourable position for needling.
Figure 1: Left Brachiocephalic AV Fistula
Preparing for the Procedure:
Prior to AV fistula formation, a duplex ultrasound of the arm veins is done to look for veins of suitable size to use. The arteries are also assessed to ensure that they are of adequate size, free from disease, and will provide adequate 'inflow' to the fistula once formed. A baseline set of blood tests will also be done.
Unless otherwise specified, all regular medications are continued prior to the procedure. Mr Milne will give you specific instructions regarding anti-platelet medications (e.g. aspirin, clopidogrel), anti-coagulant medications (e.g. warfarin, Eliquis), and any medications taken for diabetes.
Bring a small suitcase with you to the hospital in preparation for an overnight stay.
Description of the Procedure:
The procedure is usually performed under general anaesthetic. In high-risk patients, it can be done under local anaesthetic +/- sedation. A small incision is made in the arm, at the level at which the vein is to be joined to the artery. In most cases, the incision is just above the wrist or in the elbow crease. In the case of a transposition brachiobasilic AV fistula (~5% of cases), the incision is longer, and extended along the length of the basilic vein (on the inside of the arm above the elbow).
The vein and artery are carefully dissected. Clamps are applied to the artery to allow a small section to be opened. The mobilised vein is then sewn on to the artery forming a join (anastomosis). The vessels are flushed to remove debris. The clamps are then released, restoring blood flow to the artery and commencing flow through the fistula and in to the superficial vein. The anastomosis is checked for haemostasis.
The incision is closed with layered sutures, and the skin is closed with a dissolvable stitch underneath the skin. Occasionally, a small drain is left in the wound, and this is usually removed the next morning.
Following the Procedure:
You will be transferred to the vascular ward for monitoring after the procedure.You may eat and drink after 2 hours.
On the first day after the procedure, it is usual to have some mild discomfort and bruising at the site of the operation. This usually settles within a few days.
Most patients are discharged home on the morning following the procedure. In the less common case of a brachiobasilic AV fistula formation, an additional night is usually required to monitor the wound.
You will be scheduled for a review appointment with Mr Milne 4 - 6 weeks after the procedure. At this stage, for a standard AV fistula which has been made with an artery and vein of good calibre, it is usually ready to access for dialysis. A duplex ultrasound is performed at the same visit to check the size of the vein and the flow through the fistula.
It is generally advised to wait at least 1 to 2 weeks before driving a motor-vehicle. Use of the steering wheel should be unrestricted when driving.
You may fly interstate after 1 week, and may fly internationally after 4 weeks. If flying, it is important to stay hydrated and walk around the cabin regularly.
Possible Issues Following the Procedure:
- Thrombosis (clotting off) of the fistula:
- Failure to mature:
If the artery and vein are of good calibre, the fistula will mature to be ready for dialysis in >95% of cases.
The risk of encountering issues with maturation is increased if the artery or vein are suboptimal (i.e. small or diseased). There are most often treatment options to assist the maturation process.
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Malvern VIC 3144
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