Bzzz…. Bzzz…. Bzzz…. Bzzz….
Dr. Maha Al Marashi
KM. 60 Female
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Elective admission on into Beaumont
Hospital under the care of nephrology
service with poor flow through left
femoral perma-cath which was inserted.
KM. 60 Female
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BGHx:
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IDDM 1982
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Diabetic retinopathy
Diabetic neuropathy
ESRF on haemodialysis alternate days
HTN
Left subclavian vein stenosis
KM. 60 Female
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Left brachio-cephalic AVF
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Right brachio-basilic AVF
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Left subclavian stenosis
Fistuloplasty
Superficialisation
Right upper limb graft
Venoplasty right brachio-basilic AVF
Right femoral permacath
KM. 60 Female
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Doppler lower limbs:
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Patent veins which may be suitable for
fistula/ graft.
KM. 60 Female
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Left SFA-SFV groin
PTFE graft loop AVF
Sartorious muscle
mobilised medially
and laterally to
expose SFV + SFA
respectively
Venaflo graft
tunneled in loop to
lower thigh.
KM. 60 Female
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Parachute
anastamosis to SFV
and SFA.
Heparin flushing.
Haemostasis.
Closure in layers.
KM. 60 Female
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Post-operatively:
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Good bruit
Good signals
Left foot pink
No haematoma
No pain
Arterio-Venous Fistula
History
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Many advances in the treatment
of kidney failure have been seen
since the first attempts at dialysis
treatments were made in the
1920s.
The first breakthrough came in
1965 with the development of
the AV fistula at the Bronx
Veteran's Administration Hospital
in New York by Kenneth Charles
Appell.
The development of the AV
fistula has marked an important
advance, allowing effective
treatment for longer periods of
time.
Pathophysiology
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Normal blood flow in the brachial
artery is 85 to 110 mL/min. After
the creation of a fistula, the blood
flow increases to 400 to 500
mL/min immediately, and 700 to
1,000 mL/min within 1 month.
A bracheocephalic fistula above the
elbow has a greater flow rate than
a radiocephalic fistula at the wrist.
Both the artery and the vein dilate
and elongate in response to the
greater blood flow and shear
stress, but the vein dilates more
and becomes "arterialized".
When the vein is large enough to
allow cannulation, the fistula is
defined as "mature."
An arteriovenous fistula can
increase preload.
Venous Access for
Haemodialysis
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AV Fistula
AV Graft
Venous catheter (permacath)
AV Fistula “Gold Standard”
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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
Pre-op Diagnostic Tests
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Duplex arteries and superficial veins
Venogram
MRA/MRV
Surgical Techniques: Native
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A, Normal anatomy of the
right antecubital fossa,
showing the cephalic vein
(CV), median antecubital
vein (MACV), basilic vein
(BV), brachial artery (BA),
radial artery (RA), and ulnar
artery (UA).
B, Brachiocephalic
arteriovenous fistula.
C, Brachiobasilic
arteriovenous fistula.
D, Brachial artery–to–
median antecubital vein
arteriovenous fistula
Surgical Techniques: Graft
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Radial graft –
formed in the wrist
(radio-cephalic)
Brachial graft –
formed near the
elbow (brachiocephalic)
Leg graft – formed
in the thigh
Neck graft –
‘necklace graft’
Complications
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Infection
Thrombosis
Stenosis
Aneurysm/ pseudo-aneurysm
Steel syndrome
Limb ischaemia
Intervention
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Angioplasty
Stenting
Thrombectomy
Tie-off
Removal of infected graft.
Aftercare
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Making sure the access is checked before each
treatment.
Not allowing blood pressure to be taken on the
access arm.
Checking the pulse in the access every day.
Keeping the access clean at all times.
Using the access site only for dialysis.
Being careful not to bump or cut the access.
Not wearing tight jewelry or clothing near or over the
access site.
Not lifting heavy objects or putting pressure on the
access arm.
Sleeping with the access arm free, not under the
head or body.
Conclusion
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AV fistula ‘gold standard’ for venous
access for haemodialysis.
Commonly radio-cephalic in nondominant arm
Approximately 6/52 to ‘mature’
May use graft material: mature faster
but higher rate of infection
Palpate for thrill and auscultate for
bruit/ bzzz…