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People who have kidney failure or End-Stage Renal Disease (ESRD) need to get dialysis. When a person requires frequent dialysis treatment, the doctor recommends undergoing a minor surgical procedure, i.e., AV (arteriovenous) Fistula Surgery for vascular access. The creation of AV fistula for dialysis makes it easier for the dialyzer to carry blood in and out of the body several times a week. Here, you will learn all about the Arteriovenous (AV) fistula, why it is created, how the procedure takes place, risks, benefits, etc.
People who have kidney failure or End-Stage Renal Disease (ESRD) need to get dialysis. When a person requires frequent dialysis treatment, the doctor recommends ... Read More
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AV fistula surgery is a procedure in which an AV fistula is created to perform hemodialysis or peritoneal dialysis safely. It is dialysis access or vascular access surgery where the surgeons establish a connection (fistula) between the dialysis equipment and the blood vessels, i.e., arteries and veins. An access point is created as a vascular opening through which a needle or an abdominal catheter is created for hemodialysis and peritoneal dialysis respectively.
As mentioned above, an AV fistula is a connection, surgically created, between an artery and a vein. Generally, the fistula is created on the non-dominant arm to ensure that the patient can perform regular activities using the dominant hand without affecting the connection.
To form the arteriovenous fistula, an artery is directly sutured to a vein. An artery carries the blood away from the heart and delivers it to all other body parts. The pressure and flow of the blood in arteries are high. Unlike an artery, a vein has low pressure and returns blood back to the heart slowly.
When the artery and the vein are sewn together, the veins dilate over time and permit more blood to flow without damage. The dilation of the vein is a process that is called maturation which indicates that the blood vessels are ready for dialysis therapy.
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The AV fistula surgery for dialysis is recommended by a nephrologist (kidney doctor) and performed by a vascular surgeon. The vascular surgeon has to consider various essential elements for dialysis access surgery for the management of chronic kidney disease. The goal is to minimize the failure of AV fistula and to increase the patency rates with minimal interventions.
As AV fistula is usually considered the best vascular access, the patient’s health is closely evaluated, including the patient’s medical status, i.e., stage of CKD, life expectancy, comorbidities present, psychological concerns, etc. The next step is anatomic considerations, i.e., blood vessels and the presence of any arterial or venous disease.
Self-diagnosis is not possible for AV fistula surgery as it is a very complex procedure. Nerve health can only be accurately assessed by a medical professional with ample training and knowledge.
For precise vascular mapping, a doppler ultrasound (DUS) is performed as it provides clear information about the superficial and deep veins with all the necessary data on the arterial circulation, including vessel palpability, caliber, patency, course, etc. The non-invasive DUS allows a vascular surgeon to assess arterial circulation based on various morphological and functional parameters.
The morphological parameters include vessel diameter, wall thickness, wall alterations, vessel course, and steno-obstructive lesions if any. The functional evaluation includes the assessment of the artery’s ability to dilate and the blood flow.
Preoperative venous mapping is also done before the procedure. The superficial venous circulation is examined with the help of a tourniquet. Several parameters are used to decide whether the superficial vein can be used for AVF or not. These parameters include the course of the vessel, its patency, distensibility, caliber, and collateral circuits.
After the arteriovenous fistula is created for dialysis, it will gradually dilate and start maturing. Once the vein reaches the maturation point, it will be ready for dialysis treatment.
Similar to all other procedures, AV fistula surgery for dialysis also involves risks and potential complications.
Even after fistula formation is successful, the risks are not neutralized. Over the long-term, some potential risks and complications still exist but only occur in a minority of patients.
There are several things a patient can do to reduce the chances of complications after the surgery and throughout the treatment course. To care for AV fistula and protect the vascular access, follow the tips below-
Check the pulse in the vascular access every day and notify the doctor immediately if any changes occur.
There are three major types of vascular access. Two of them, i.e., an arteriovenous fistula and AV graft are for long-term use. The third type is for a short term known as the venous catheter.
An AV fistula is created by joining an artery and a vein together. The surgery is performed to dilate and expand the vein so that the hemodialysis treatment can be carried out safely. The AV fistula is recommended over other types of access because it provides good blood flow, lasts longer than other types of access, and is less likely to get infected or blocked over the course of treatment.
The AV fistula requires at least 2-3 months to develop and mature before it’s safe for dialysis treatment. If the fistula fails to mature, the patient has to undergo repeat the procedure or choose alternatives.
An AV graft is different from a fistula as it uses an artificial plastic tube to connect the artery and the vein. The graft is looped, one end is connected to the artery and the other end is connected to the vein. This procedure is preferred when the patient doesn’t have enough time to wait for an AV fistula to mature. The AV graft is usually ready for use within 2-3 weeks after the surgery.
The third option for vascular access is using a venous catheter. It is a tube that is inserted into a vein in the neck, chest, or near the groin. The tube is connected with a large central vein. Fluoroscopy (a type of X-ray) is used to guide the catheter and place it into the chosen vein.
This method is chosen when the kidney disease progresses rapidly and the patient may not have enough time for placement of AV fistula or graft. The venous catheter will for several weeks or months but eventually, a long-term vascular access surgery will be required for dialysis.
All AVF for dialysis has very similar characteristics. They are all created by using native vessels without using any synthetic material. Three of the most commonly created fistula for dialysis are-
It is very difficult to create this type of fistula. The radial artery and the cephalic vein are connected for anastomosis. The radial cephalic fistula has lower blood flow as compared to the other two types but it preserves the arm vessels in a better way. It is usually the first choice for hemodialysis access.
This type of fistula is created using the cephalic vein in the upper arm and connecting it to the brachial artery. Since the size of the blood vessels in the arm is larger, the fistula is easy to create. It generally requires minimal dissection and also has a larger possible selection of cannulation sites. The brachial cephalic fistula permits more blood to flow through the blood vessels during dialysis treatment but also has a higher risk of steal syndrome.
This type of arteriovenous fistula requires the vein to be elevated and transposed to achieve stable vascular access. The connection is made between a mobilized vein (deep vein) to a superficial artery. It can be preserved in a better way but also has a higher rate of patient morbidity as compared to other fistulas. It is typically created in patients who have had failed access procedures multiple times.
The steps a patient takes before the surgery can improve the outcome of the procedure. Thus, it is advised to be well-prepared in all aspects before undergoing the procedure-
Answer all the questions asked by the doctor regarding the medical history and medications. This includes prescriptions, OTC drugs, herbal treatments, and vitamins too.
Make the necessary modifications in diet and try to lose excess weight to improve your overall health.
Talk to the doctor to control high blood pressure as it can increase the risk of complications of AV fistula surgery.
Avoid drinking or eating 6-8 hours prior to the surgery.
Stop smoking entirely as it will delay the healing process and also make the blood vessels weak.
If any medications are prescribed by the doctor before starting the dialysis treatment, take them as directed without any failure.
Externally, there won’t be significant changes. Internally, the patient will be able to see the thickened vein that will be used for dialysis access. A pulse can also be felt in the blood vessels.
The cost of AV fistula surgery in India ranges from Rs. 80,000 to Rs. 1,50,000 approximately. The exact cost may vary based on the following factors-
Complexity of the procedure (veins used to create AV fistula)
Surgeon’s fee
Diagnostic tests
Risks and complications
Anesthesia charges
Hospital-related expenses
Post-surgery care and follow-ups
Any or all conditions that affect kidney functions come under critical illnesses and are covered under most health insurance plans. The treatment for CKD or kidney failure is medically necessary to save the life of the patient. Thus, the health insurance policy provides coverage for AVF surgery for dialysis.
The surgery will be performed around 6-7 months before the first dialysis treatment takes place. So, the insurance claim can be filed directly to cover the expenses or the patient can use a reimbursement claim. Most of the expenses associated with the treatment will be included in the policy and the insurance providers will also explain the exclusions. It is advised to talk to the insurance provider regarding the terms and conditions of the policy.
The recovery after AV fistula surgery for dialysis is a gradual process. The arm in which the fistula is created will be sore and numb for several days. In the next few days after surgery, the discomfort will go away and the fistula will start to heal and enlarge.
Over the next 2-3 months, the fistula will mature and become strong enough to withstand the regular needle insertion and dialysis treatment.
The vein needs to be enlarged before hemodialysis treatment as they are smaller in size. Veins usually have lower pressure and less blood flows through them. For the dialyzer to filter blood efficiently, the veins should be enlarged and allow extra blood to flow through them.
As the skin is cut to create a fistula, there may be minor scarring on the skin. Overtime, the cut will heal and the scar will fade away.
The pain during the surgery is controlled by anesthesia and afterward, pain medications are prescribed by the doctor to provide relief from the pain and discomfort.
No. All patients are not suitable for AV fistula surgery. The blood vessels need to be strong enough to handle the frequent dialysis treatment. If the patient’s blood vessels are normally not strong, then the fistula won’t mature. As a result, the doctor has to use alternative methods for vascular access.
During the hemodialysis treatment, local anesthetic cream is used to numb the area. Two needles are inserted into the fistula, one in the artery and one in the vein. The dialysis is started and takes around 2-3 hours to complete, but the procedure doesn’t hurt. A stinging sensation may be felt when the needles are inserted. Besides that, there will be no pain or discomfort.
