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Bzzz…. Bzzz…. Bzzz…. Bzzz…. Dr. Maha Al Marashi. KM. 60 Female. 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. BGHx: IDDM 1982 Diabetic retinopathy Diabetic neuropathy

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  1. Bzzz…. Bzzz…. Bzzz…. Bzzz…. Dr. Maha Al Marashi

  2. KM. 60 Female • Elective admission on into Beaumont Hospital under the care of nephrology service with poor flow through left femoral perma-cath which was inserted.

  3. KM. 60 Female • BGHx: • IDDM 1982 • Diabetic retinopathy • Diabetic neuropathy • ESRF on haemodialysis alternate days • HTN • Left subclavian vein stenosis

  4. KM. 60 Female • Left brachio-cephalic AVF • Left subclavian stenosis • Right brachio-basilic AVF • Fistuloplasty • Superficialisation • Right upper limb graft • Venoplasty right brachio-basilic AVF • Right femoral permacath

  5. KM. 60 Female • Doppler lower limbs: • Patent veins which may be suitable for fistula/ graft.

  6. KM. 60 Female • 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.

  7. KM. 60 Female • Parachute anastamosis to SFV and SFA. • Heparin flushing. • Haemostasis. • Closure in layers.

  8. KM. 60 Female • Post-operatively: • Good bruit • Good signals • Left foot pink • No haematoma • No pain

  9. Arterio-Venous Fistula

  10. History • 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.

  11. Pathophysiology • 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.

  12. Venous Access for Haemodialysis • AV Fistula • AV Graft • Venous catheter (permacath)

  13. AV Fistula “Gold Standard” • 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

  14. Pre-op Diagnostic Tests • Duplex arteries and superficial veins • Venogram • MRA/MRV

  15. Surgical Techniques: Native • 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

  16. Surgical Techniques: Graft • Radial graft – formed in the wrist (radio-cephalic) • Brachial graft – formed near the elbow (brachio-cephalic) • Leg graft – formed in the thigh • Neck graft – ‘necklace graft’

  17. Complications • Infection • Thrombosis • Stenosis • Aneurysm/ pseudo-aneurysm • Steel syndrome • Limb ischaemia

  18. Intervention • Angioplasty • Stenting • Thrombectomy • Tie-off • Removal of infected graft.

  19. Aftercare • 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.

  20. Conclusion • AV fistula ‘gold standard’ for venous access for haemodialysis. • Commonly radio-cephalic in non-dominant 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…

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