Procedures

Arteriovenous Fistula (AV Fistula)

Description:

Vascular access (Arteriovenous fistula) is a term that describes a surgical procedure which is done to prepare a patient for hemodialysis.
When the patient's kidneys stop working, they are unable to cleanse the blood of waste products. One of the methods to replace that function is called hemodialysis. The hemodialysis machine is able to process a large volume of blood quite rapidly. A patient's veins are not constructed in such a way that they can tolerate high pressures or high flows. There are 3 ways to provide adequate flows and pressures for successful hemodialysis. They are by creating an arteriovenous fistula, an arteriovenous graft, or insertion of a specialized catheter into the central venous system.

The most common and preferred procedure is an arteriovenous FISTULA. The surgeon identifies a suitable sized artery and vein in the arm and, through a fairly small incision, surgically attaches the vein to the artery. This allows a portion of the high pressure blood in the artery to enter the low pressure and thin-walled vein. Over time, the vein gradually enlarges and has increased blood flow volume. Often this "development" of the fistula requires two months.

Risks:

The more common risks include: infection, bleeding, nerve injury, blood clots, heart attack, allergic reactions, and pneumonia. These risks can be serious and possibly fatal. The significant risks of this procedure were discussed with emphases on: Thrombosis, chronic pain, limb threat, ischemia, failure to develop fistula, graft failure, graft narrowing, pseudoaneurysm

Pre operative information:

Before your surgery, you will be required to have a pre admission testing appointment. At this appointment, you will be registered at the hospital; you will have lab work done and possibly a x-ray. You will also meet with an anestheologist.

Information about the day of surgery:

No food starting midnight the night before surgery. Solid food must be avoided the day of surgery-regardless of the surgery time. Clear liquids must be stopped four (4) hours before your surgery.

Clear liquids are considered: water, apple juice, cranberry juice, black coffee (no cream), tea, and soda (7-UP, pepsi, ect).

Length of recovery:

The surgery is low impact to the patient and is done as a "day surgery" procedure. Normal use of the arm and activity is maintained after surgery.

Post operative information:

AV Fistula/Graft Post-Surgery Guide

The following information is intended to guide you through your post-op recovery:

Diet:

For the first few days after your return home you should eat foods that you easily tolerate normally.

Medications:

Follow the directions on any new prescriptions that your doctor has given you. You may return to taking your regularly scheduled medications on the day of your surgery, unless your doctor has directed you otherwise.
Pain management is an important part of your post-surgery care. You should expect some discomfort after your surgery. You may be sent home with a prescription for pain medication. It is important to take your pain medicine prior to your pain becoming intense in severity.

PLEASE NOTE:

No pain medication refills will be authorized on the weekends. If a refill is needed, the request must be made before 12:00 noon on Friday.
Some side effects from the pain medications include nausea and constipation. If you experience nausea or vomiting related to your pain medications, you should stop the medication and take ibuprofen or acetaminophen for pain management.

Bowel Care:

To prevent constipation you should drink plenty of fluids and take a stool softener daily.
If you have not had a bowel movement within 48 hours after your return home, you should increase your fluid intake. You may take one single dose of Milk of Magnesia, as long as you have no abdominal distention.

You may remove the gauze dressing over your incision 48 hours after your surgery. Please leave the skin tapes in place for approximately 7-10 days.
If your clothes irritate the incision or if you have some drainage you may leave a dry gauze dressing over your incision.
If you have staples or stitches, they will usually be removed 1- 2 weeks after your surgery. You will need to make an appointment to come to the office for that.
You must observe your incision daily for signs or symptoms of infection. These signs would include: increased swelling, redness or smelly wound drainage. It is normal to have some swelling and bruising around your incision.

Fistula information/care:

It is normal to have swelling in the surgical area. To help control this swelling you can elevate your arm on a pillow (although, you should not do this if it causes you increased discomfort in your hand.)
The fistula or graft can not be used until the MD has given approval. Generally, a graft will be ready to use in 2 weeks, and a fistula will be ready to use in 6-8 weeks.
It is important that you notify our office if you are having numbness and significant pain in the extremity in which you have just had surgery!!
You will need to regularly exercise the hand and fingers of the extremity that has been operated on. The appropriate exercises include squeezing a ball in your hand for 2-3 minutes two to three times each hour you are awake.

Please read and follow the dialysis unit’s instruction sheet that is attached.

Bathing and Showering:

You may shower after you remove your dressing which will be 48 hours post-surgery. You may shower with your steri-strips in place. Do not scrub across your steri-strips. Do not bathe in a tub for 10-14 days after your surgery. This includes a “hot tub”.

Driving:

You may drive when you no longer are taking narcotic pain medications and you feel you can quickly respond to situations that will not place others in jeopardy.

Return to Work:

Your doctor should inform you of when you might return to work (usually within 1-2 weeks). Please notify our office if you need a return to work letter to your employer. It may take up to 48 hours for the letter to be completed. Please leave a fax number for your employer so we can fax your release

Follow-up Appointments:

You will need to return to the office for a follow-up visit usually within 2 weeks after your surgery. Please make sure you have your appointment scheduled.
You will also need to have another appointment 4 to 6 weeks after your surgery for further evaluation.

Problems to Observe For:

Call the office for the following:
1. Fever >101.0
2. Uncontrolled pain. That is on a scale of 1-10 (10 being the worst pain imaginable) your pain is a level 7 or above.
3. Nausea and / or vomiting that continue for 12-24 hours.
4. Diarrhea that continues for 12-24 hours.
5. Signs of a wound infection.
6. Chest pain or difficulty breathing
7. Your incision separates or opens up.

If you have further questions after reading this handout, the office is open from 9:00AM to 5:00PM Monday through Friday. For emergencies after office hours, the answering service will be available when you call the office number.

Care of the new fistula

Copied courtesy of the Oregon Dialysis Center.

In order for dialysis personnel to use the fistula it must dilate or enlarge to a size that will accommodate large bore needles. This is best achieved by the patient exercising the access arm. You, the patient, should start learning how to care for your access immediately after surgery by following the protocol below.

Step 1

Keep arm elevated (above your heart) starting immediately after surgery and for the next 1-2 weeks or until the swelling is diminished. Wiggle your fingers and clinch your fist 10 times every hour, while awake, for the first 5-7 days. Also, bend and straighten at the elbow to regain normal range of motion. These exercises are designed to promote circulation in the fingers and aid in draining away the excess fluid accumulation in the immediate area. If numbness is present, sensation will return sooner if the exercises are done as prescribed.

If symptoms of numbness, tingling, weakness, and or coldness persist, without improvement, a return visit to your surgeon is warranted as soon as possible as this can be a sign of a more serious problem.

Step 2

On post-op day number 5, you should begin squeezing a rubber ball. The dialysis unit usually can provide one, if not a tennis ball will work. Squeeze the ball 10 times every hour and hold the squeezed position for 3-5 seconds each time before releasing grip. This helps the vessel wall to strengthen and thicken so it will seal up quickly and won’t leak into the surrounding tissue after the needles are removed. It also dilates or engorges the vessel by trapping blood in it under pressure during the 3-5 second hold phase.
This exercise is crucial in the development, or “maturation”, of the fistula and may need to be performed for several months.

Step 3

Each day, using your opposite hand, feel over fistula for the “thrill” or vibration that is normally present. Also bring your access arm up to your ear and you may be able to hear the ‘bruit’ or buzzing-the rushing ocean sound. If either one of these are not present, call the dialysis unit for instructions. This is a sign that your fistula is about to clot or already has and requires medical attention.

Healthcare personnel:

1. Avoid blood draws or IV starts in the access arm.
2. Avoid blood pressure readings in the access arm.
3. Avoid use of tourniquets or other pressure holding devices after needle removal when your fistula is brand new 0-6 weeks. Manual pressure is best, preferably by the patient.

The patient (you) should :

1. Avoid wearing tight constrictive clothing over that arm.
2. Avoid wearing jewelry that is tight, such as a watch on the access arm.
3. Avoid carrying heavy objects.
4. Avoid purse straps over the fistula.
5. Avoid sleeping on the arm or keeping it bent for extended periods of time.

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