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Everything You Should Know About AV Fistula for Dialysis

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.

Table Of Index

What is AV Fistula Surgery?

How is an AV Fistula for Dialysis formed?

Types of AV Fistula Surgery

Need

Symptoms

Diagnosis

Risks & Complications

When to consult a doctor ?

Questions to ask your doctor .

Treatment options & cost

Insurance coverage

Recovery rate

Long term outlook of the treatment

What is AV Fistula Surgery?

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.

How is an AV Fistula for Dialysis formed?

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.

Types of AV Fistula Surgery

Radial Cephalic Fistula

Brachial Cephalic Fistula

Brachial Basilic Fistula

Need

Autoimmune diseases

Certain inherited diseases, including polycystic kidney disease

Conditions such as shock and renal artery stenosis

Kidney inflammation caused by nephritis and glomerulonephritis

Poorly treated and untreated chronic diseases, including diabetes and high BP

Trauma to the kidneys or arteries that supply blood to the kidneys

Urinary tract obstructions, including kidney stones, tumors, congenital deformities, & enlarged prostate glands

Kidney cancer

Symptoms

Diagnosis

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.

Preoperative Vascular Mapping

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.

Risks & Complications

Similar to all other procedures, AV fistula surgery for dialysis also involves risks and potential complications.

Reaction to anesthesia
Bleeding, that can lead to shock
Blood clots that develop in the AV fistula
Infection in the fistula and surrounding tissues
Swelling in the arm
Numbness in the surgical site due to bruising of a nerve

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.

Clotting of fistula- It means the blood stops flowing through the fistula. In some cases, the clot may get stuck and it may be difficult to remove it. As a result, a different type of access will be created for dialysis.
Steal syndrome- There is a slight possibility that the blood flow in the artery may get affected if a large amount of blood directly passes through the vein. Due to this, hand movements may get affected. To correct the blood flow, another operation may be required.

Infection– The chances of infecting the wound or the fistula itself remain long after the surgery is complete. If this happens, antibiotics will be needed.

After-Surgery Care Tips
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.
- Follow the diet and lifestyle restrictions and recommendations advised by the doctor as long as the AV fistula is being used for dialysis treatment.
- Inform the doctor right away if there are signs of pregnancy or conception.
- Do not allow healthcare personnel to draw blood or take blood pressure readings from the arm where the AV fistula is located.
- Do not constrict the arm by sleeping on it or wearing tight accessories that can disrupt the blood flow.
- Let the doctor know if there is bleeding, redness around the wound, consistent pain, fever, swelling, or drainage from the fistula.
- Avoid lifting heavy objects with the AV fistula arm and protect it from injuries.
- Take the dialysis treatments and prescribed medications as directed by the doctor.
Rule of 6S for Fistula Maturation
The maturation of AV fistula created for dialysis is defined by the commonly accepted 6s rule. This rule states that a fistula is matured, i.e., ready and safe for use if-
- The flow of blood is greater than 600 mL per minute.
- Diameter of the vein is greater than 6 mm.
- It is located 6 mm below the skin surface.
- A minimum 6 cm of the vein is safe to use for cannulation.
- At least 6 weeks have passed since the creation of the fistula.

When to consult a doctor ?

The right time to consult a vascular doctor to undergo AV fistula surgery is during the end stage of chronic renal disease or kidney failure. This will give the surgeon ample time to diagnose the overall vascular health of the patient. Thus, the doctor can determine whether or not AV fistula surgery is the best option for vascular access to permit dialysis treatment required in the upcoming months.

Our av-fistula Specialist

Questions to ask your doctor .

Treatment options & cost

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.

Arteriovenous Fistula Surgery

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.

Arteriovenous Graft Surgery

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.

Venous Catheter

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-

1: Radial Cephalic Fistula

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.

2: Brachial Cephalic Fistula

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.

3: Brachial Basilic Fistula

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.

The AV fistula surgery is performed on an outpatient basis at a hospital by an experienced vascular surgeon. The surgical team will clean the surgery site and start anesthesia. General, local, or regional anesthesia may be used depending on the patient’s condition.

The surgery will be performed in the following steps-

Once the anesthesia takes effect, an incision is made in the site.
The chosen vein and artery are identified and the blood flow through the chosen blood vessels is halted temporarily.
The artery and vein are adjoined without any external support through stitches and the blood flow is restored.
The incision is then closed and the fistula is left to mature over the next several months.

Immediately after the surgery, the patient is transferred to the observation room. A tube may be placed in the windpipe to control breathing after general anesthesia is given.

The surgical team will monitor the vital signs and other critical body functions for the next few hours. Once everything is normal, the patient is cleared for discharge. Before leaving the hospital, the doctor provides a recovery plan that consists of the dos and don’ts after the surgery.

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

Insurance coverage

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.

Recovery rate

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.

Video testimonial - by patient

Video on the disease and treatment - by Pristyn Care doctor

Latest Research

Future research directions to improve fistula maturation and reduce access failure
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A national cohort study on hemodialysis arteriovenous fistulas after kidney transplantation – long-term patency, use and complications
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Predictors of Arteriovenous Fistula Failure: A Post Hoc Analysis of the FAVOURED Study
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Factors Influencing AVF Dysfunction in Patients with Maintenance Hemodialysis: A retrospective study
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Cities Where We Treat Av-fistula

Av-fistula treatment in Agra

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Av-fistula treatment in Dehradun

Av-fistula treatment in Delhi

Av-fistula treatment in Faridabad

Av-fistula treatment in Ghaziabad

Av-fistula treatment in Gurgaon

Av-fistula treatment in Hyderabad

Av-fistula treatment in Jaipur

Av-fistula treatment in Kolkata

Av-fistula treatment in Mumbai

Av-fistula treatment in Mysore

Av-fistula treatment in Noida

Av-fistula treatment in Pune

Av-fistula treatment in Vijayawada

Av-fistula treatment in Visakhapatnam

FAQ

What does the vein need to be enlarged for hemodialysis 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.

Does AV fistula surgery leave a scar?

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.

Does AVF surgery hurt?

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.

Is AV fistula suitable for every patient with kidney diseases?

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.

Will the fistula hurt while it is being used?

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.

Facts

In 2018, around 175,000 people in India had chronic kidney disease and needed dialysis treatment.

How Pristyn Care can help you?

Pristyn Care is a dedicated healthcare provider that focuses on delivering holistic medical services to everyone who needs them. We have a highly experienced and skilled team of vascular surgeons and interventional radiologists who can safely create the AV fistula for dialysis.

You can schedule an appointment with any of our specialists near you and have a detailed discussion about the need of AV fistula surgery and what it entails. We bring our full range of medical capabilities and best-in-class services to every patient.

Book a free appointment with our vascular surgeons and undergo AV fistula surgery as planned to prepare the body for dialysis treatment.

Book A Free Appointment with the Best Vascular Surgeons to Undergo AVF Surgery for Dialysis

To consult the expert vascular surgeons in your city, get in touch with Pristyn Care. You can consult our experts to undergo AV fistula surgery safely. To book an appointment with them, you can-

Give us a call on the number given at the top.
Fill out the “Book Appointment” form.
Download Pristyn Care mobile app.

Pristyn Care is focusing on making advanced surgical treatments accessible to every patient who needs them. So, schedule your appointment and consult our specialists for free to plan AFV surgery for dialysis.