Arteriovenous Fistula Creation

OVERVIEW

Arteriovenous fistula creation is a surgical procedure performed by a vascular surgeon to create a connection between an artery and a vein. The fistula is usually placed on the forearm or upper arm; however, it may also be placed on the leg. 

The creation of an AV fistula increases pressure and blood flow through the vein, which makes the vein grow larger and stronger.  The enlarged vein provides easy and reliable vascular access for life-saving hemodialysis treatments. 

INDICATION

An arteriovenous fistula may be indicated for treatment of end-stage renal disease. This is a common condition caused by diabetes or hypertension and is characterized by progressive loss of the kidney’s ability to filter and purify the blood. 

PRE-OP PREPARATION

In preparation for an AV fistula creation, a Doppler ultrasound will be performed to map the blood vessels. The ultrasound shows the speed of blood flow through the various blood vessels in the area, enabling your surgeon to choose the most appropriate blood vessel for the fistula.

You will need to inform your doctor about any allergies and medications you take regularly as certain medications such as blood-thinners may have to be stopped temporarily about a week before the procedure. 

You may be asked to avoid eating and drinking after midnight on the day prior to surgery.

PROCEDURE

An arteriovenous fistula creation involves the following steps:

• The skin over the AV fistula site is cleaned with an antiseptic solution and local anesthesia will be administered to numb the area.

• Alternatively, general anesthesia may be administered so you are asleep during the procedure. With local anesthesia, you remain awake and may feel some pressure at the site, but no pain.

• A small incision will be made to gain access to the blood vessels.

• The selected artery and vein are incised and surgically connected with sutures.

• The skin incision is then closed with sutures and a bandage is placed over the incision.

RECOVERY AND POST-OP CARE

AV fistula creation can be performed in an outpatient setting and most patients can expect to be discharged after a few hours in the recovery room. There may be a slight discharge for 24 hours and soreness from the incision site for a few days after surgery. You will be given medication for any postoperative pain and advised to keep the arm elevated to reduce swelling. Specific instructions will be given on how to care for the AV fistula access site.  It takes about 2 to 3 months before the fistula is developed and mature enough to be used for hemodialysis.

To protect the access site, you should take the following precautions:

• Wash the vascular access site every day and keep it clean and dry.

• Ensure that your doctor checks the access site before each hemodialysis treatment.

• Use the access site only for dialysis.

• Be careful not to bump or injure the access site.

• Check for thrill (a rhythmic vibration) over the access site, which indicates the AV fistula is healthy.

• Do not put a blood pressure cuff, tight clothing, or jewelry over the access site.

• Do not lift heavy objects with the access arm.

• Avoid sleeping with the access arm under your head or body.

• Report any signs of infection such as redness, swelling, or pus drainage to your doctor as soon as possible.

RISKS AND COMPLICATIONS

AV fistula creation is a safe procedure; however, as with any surgery there are some risks and complications involved that may include:

• Excess bleeding

• Infection

• Swelling

• Pain

• Formation of clots that may slow down or block the AV fistula

BENEFITS AND ADVANTAGES

Some of the benefits of an AV fistula in the treatment of end stage renal failure include:

• Can be used for a longer time compared to other types of vascular access

• No foreign material is implanted into the body

• Optimizes blood flow for effective hemodialysis while minimizing treatment time

• Lowers infection risk

• Can be performed in the outpatient setting

• Ensures faster recovery and return to routine activities

SURGICAL INSTRUMENTS & O.R. NEEDS

INSTRUMENTS:

AVF Set (the following instruments included in this set are as follows):

Mayo Curve/Mayo Straight

Metz Curve

Tenotomy Curve

Knife Handle

Mosquito Curve/Mosquito Straight

Mixter

Towel Clips

Debakey Forceps

Adson Forceps

Gerald Forceps

Needle Holder

Ryder/Castroviejo

Dilators

Bulldog Curve

Army Navy

Senn Retractor

Small Weitlaner

Kidney Basin

Small Bowl

Pott’s Scissors

EXTRA Gerald Forceps

EXTRA Senn Retractor

EXTRA Small Weitlaner

EXTRA Castroviejo

O.R. NEEDS:

Operating Sponge

Gloves 6, 61/2, 7 and 71/2

Syringes (1cc and 10cc)

Cautery Cord (short tip)

Feeding Tube Fr. 8 (for shudding of mosquitoes)

Cautery Pad

IV Cannula G20

Blade 11 and Blade 15

Lidocaine 2%

Heparin

Tegaderm (small)

Tourniquet (optional/standby)

Marker (optional/standby)

Povidone Iodine 7.5%

Povidone Iodine 10%

Alcohol

Silk 4.0 (strands)

Prolene 6.0 BV1/Prolene 7.0 BV1

Vicryl 4.0 PC5/ Vicryl 4.0 RB1