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 ESRF on haemodialysis alternate days

HTN Left subclavian vein stenosis

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

KM. 60 Female

Doppler lower limbs: Patent veins which may be suitable

for fistula/ graft.

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.

KM. 60 Female Parachute

anastamosis to SFV and SFA.

Heparin flushing. Haemostasis. Closure in layers.

KM. 60 Female

Post-operatively: Good bruit Good signals Left foot pink No haematoma No pain

Arterio-Venous Fistula

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.

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.

Venous Access for Haemodialysis AV Fistula AV Graft Venous catheter (permacath)

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

Pre-op Diagnostic Tests

Duplex arteries and superficial veins

Venogram MRA/MRV

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

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’

Complications

Infection Thrombosis Stenosis Aneurysm/ pseudo-aneurysm Steel syndrome Limb ischaemia

Intervention

Angioplasty Stenting Thrombectomy Tie-off Removal of infected graft.

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.

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…