Introduction

The Basics

In general, there are two types of dialysis accesses that can be created for hemodialysis. The first type of access if called a graft. A graft involves connecting an artery and vein with a piece of prosthetic (Gore-Tex). This involves placement of foreign body. The second type of access which is preferred is called a fistula. A fistula is an abnormal connection between your own artery and your own vein. There is no foreign body inserted. The benefits of fistula formation include less chance of infection, greater viability and longevity of the access itself. A graft also affords access to your circulation for hemodialysis, however, does not last as long and has higher risk of infection and “rejection” from the body itself. Grafts last on average one year before they need to be replaced or altered in some way. Fistulas, on the other hand, have a much longer lifespan with many fistulas lasting lifetime (for all dialysis days). Nationwide, there has been an effort to transition people from grafts to fistulas. Nationally, the “Fistula First Initiative” was developed in order to educate the medical and surgical community as to the benefits of fistula versus graft. There are a number of different fistulas available. To name four: 1) Brescia-Cimino; 2) Brachiocephalic; 3) Brachiobasilic, 4) Basilic vein transposition. These are the most commonly created fistulas. However, there are many other types of secondary/creative fistulas that your surgeon will discuss with you should you be a candidate.

At all costs, your nephrologist and vascular surgeon would like to avoid placement of temporary dialysis catheters. A temporary dialysis catheter is inserted usually into the large vein of the neck, exiting out onto the chest wall. Certainly, this is a very useful tool in bridging patients while their formal access is healing; however, there are multiple complications associated with long-term catheter use. Your nephrologist has explained to you the goal is to remove and avoid catheters at all costs.

Office Evaluation

During your initial office evaluation, a history and physical exam will be performed by the operative surgeon. He will review all of your previous access attempts, if any. In addition, documentation of medications, i.e. use of anticoagulation medicines (blood thinners), documentation of previous catheter placements, documentation of other medical devices in the venous tree. In addition, at the same office evaluation, an ultrasound mapping will be performed of one or both arms. The ultrasound mapping is painless. It involves placing a probe on the outside of the arm which will look at the arteries and veins in the arms themselves. The size of these veins and the patency of these veins are of paramount importance in predicting and documenting success of fistula formation.

The type of fistula planned will be determined by history, physical, and ultrasound mapping.

What You Should Bring to Your Initial Evaluation:

• Detailed history involving all previous operative procedures.
• Detailed list of your medications.
• Any cardiac or other work up that has been performed in the past (within the last six months). This would involve cardiac stress test, echocardiogram or electrocardiogram along with a copy of your last letter from your cardiologist’s last visit. If you have had a cardiac catheterization in anticipation of need of kidney transplant, this should also be included.

Scheduling

When calling our office, please mention you are a dialysis access candidate and need to be placed through the Fistula Fast Track Program. The Fistula Fast Track Program was initiated in order to decrease the amount of time from initial evaluation to operative procedure for dialysis patients. There is a contact person in our office who will make sure that you are evaluated in a timely fashion.

Once you have been evaluated in the office, you will meet with one of our schedulers. You do have a choice of facilities where the surgery itself can be performed. The majority of these operative procedures are performed as an outpatient. The scheduler will discuss preadmission testing including blood work that will be necessary prior to your operative procedure. There will also be instructions given as to maintaining or discontinuing certain medications. There also may be a preadmission testing evaluation at the hospital or facility where you are going to be scheduled.

Day of Surgery:

• You will have been given instructions in terms of maintaining or discontinuing your standard medications.
• You will check in at admissions at the facility where you are scheduled. You will have received a call the day prior to your operative procedure in order to assign you a time of arrival.
• After checking in at admissions, you will be escorted to the operating room holding area. You will be greeted and evaluated by a holding area nurse. You will undergo an interview with one of the anesthesiologists who will discuss the types of anesthesia that are available to you. The type of anesthesia will also have been discussed with you by your operative surgeon. This most likely will have been predetermined prior to your arrival at the hospital. Your operative surgeon will greet you and marked your arm prior to surgery. Any last minute questions will be answered.
• The majority of access surgery requires one to one and a half hours of operating room time. Again, this may vary depending on the complexity of your operative procedure.

Complications and Risk Factors

The chance of success, i.e. creation of usable fistula, is approximately 70%. This means that there is a 30% failure rate for each fistula attempt. All patients need to know that if the first fistula attempt fails then we need to regroup and attempt another fistula at another site. The complications and risk factors for fistula surgery include bleeding, infection, steal syndrome, and ischemic neuropathy. Because arteries and veins are being connected, there is potential for bleeding. You will be given instructions in terms of how to monitor and identify this complication. Infection is rare with fistula surgery. One large dose of perioperative antibiotic typically is administered prior to surgery to drop the infection rate to less than 1%. There has been an entity described with access surgery called steal syndrome. As the name implies, steal syndrome is caused by re-routing of blood away from the arterial tree. In severe cases, this may lead to numbness and tingling in the extremity distal or downstream from the fistula itself. Rarely, steal syndrome becomes severe enough that the fistula needs to be ligated or abandoned and another attempt planned. The fourth complication always mentioned in access surgery is something called ischemic neuropathy. This is a rather vague process, the etiology of which is unclear. However, we believe that there is alteration or lack of blood flow to the nervous structures distal to fistula formation which may lead to both motor and sensory dysfunction in the hand itself. This usually requires reversal or ligation of the fistula and initiation of occupational and physical therapy. There is no way to predict who will develop ischemic neuropathy. Be assured it is a very rare complication.

Recovery

Initial recovery period after your operative procedure will occur in the recovery room (PACU). Routinely, one hour is spent in the recovery room. From here you will either be discharged or sent to the short procedure unit for additional recovery time. The amount of time spent in the SPU unit is variable depending on the type of anesthesia and the type of fistula created. When you are discharged home, you should rest for the remainder of the operative day. Normal activities can be resumed the day after surgery.

Limitations

There should be no heavy lifting on the operative side. The operative arm should be kept straight, elevated, and away from the body during waking hours. Avoid prolonged periods of bending the elbow. Do not sleep on the side of the surgery with the arm bent.

Wound Care

Steri-strips or butterflies will be applied across your surgical incision. These stay in place for approximately one week. It is not unusual to have some mild bleeding through the Steri-strips. The operative site can be covered with a gauze pad as needed.

Follow-up

A postoperative visit will be necessary. The first postoperative visit should be 10 to 14 days after the operative procedure. Please call the office to make this appointment. Periodic visits will be made after the operative procedure to monitor maturation or progression of healing at the fistula site itself. In addition to routine physical exams at the time of postoperative visit, an additional ultrasound may be performed in the office to monitor enlargement of the vein segment itself. Your operative surgeon will discuss this with you.

Commonly Asked Qustions

Q: Will I be able to use my arm after surgery?
A: Yes, you will be able to use your arm very quickly for normal activities of daily living. We do ask that you limit lifting to between 10 and 15 pounds until seen in the office at 10 to 14 days. Eventually, you will be able to use the arm as you did preoperatively.

Q: What happens if my fistula does not mature?
A: After re-evaluating any fistula after two to three months, if it has not matured adequately, then you will be placed through a re-evaluation protocol. Most likely some type of a revision to the existing fistula or creation of a new fistula will occur.

Q: What happens if I need dialysis before my access matures?
A: If urgent or semi-emergent dialysis is needed and any patient does not have adequate vascular access, then a temporary catheter (Permacath) will be placed to bridge the gap. Once the access has matured, then the Permacath/temporary catheter will be removed.

Q: Will my fistula show?
A: Depending on what type of fistula has been created, it is not unusual to have some dilatation of the veins in the arm. On occasion, over time, a fistula will become aneurysmal. This means that there will be larger areas along the course of the dilated vein that become “bumpy”.