Arteriovenous (AV) Fistula SurgeryBy
Catherine Spader, RN
What is arteriovenous (AV) fistula surgery?
Arteriovenous (AV) fistula surgery creates a place to access the body’s circulatory system to perform dialysis. Dialysis removes wastes and extra fluid from the blood when the kidneys can no longer perform this function. This is known as kidney failure. An AV fistula allows blood to flow from your body to the dialysis machine and back into your body after filtering.
AV fistula surgery involves sewing together an artery and a vein, usually in the wrist or elbow area. This creates a larger, tougher vein that can tolerate multiple needle punctures that are needed for dialysis. You can see the thickened vein and feel a pulse in it after the AV fistula heals over several months.
AV fistula surgery is only one dialysis access option. It may not be the best option for everyone, such as people with small blood vessels. Other options include an AV graft (an artificial blood vessel) and a venous catheter, which is for short-term dialysis. AV fistula surgery is generally for people who need long-term dialysis and have healthy blood vessels.
Consider getting a second opinion about all your dialysis access choices before having AV fistula surgery.
Why is arteriovenous (AV) fistula surgery performed?
Your doctor may recommend arteriovenous (AV) fistula surgery as part of a complete dialysis treatment plan for kidney failure. Kidney failure is a life-threatening condition. It causes a buildup of waste and fluid in the body due to poor kidney function. Dialysis uses a machine to filter wastes and extra fluid from the blood.
People with kidney failure may require dialysis permanently or for a short time. Sometimes, kidney failure that occurs suddenly (acute kidney failure) can be reversed by rapidly treating the cause. Reversible causes can include a drug overdose, shock, or a kidney infection.
AV fistula surgery is used for long-term dialysis for permanent or chronic kidney damage. People who have AV fistula surgery may be waiting for a kidney transplant. AV fistula surgery may be needed for kidney failure that results from:
Autoimmune diseases including systemic lupus erythematosus that affects the kidneys
Certain inherited diseases including polycystic kidney disease, which causes large cysts in the kidneys that damage kidney tissue
Conditions that reduce blood flow to the kidneys including shock and renal artery stenosis (narrowing of the renal arteries)
Diseases that cause kidney inflammation including nephritis and glomerulonephritis
Infections including repeated bladder infection, pyelonephritis (kidney infection), or septicemia (blood infection)
Medication use or abuse including intravenous (IV) drug abuse, overdose of certain drugs, or long-term use of certain medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs)
Poorly treated or untreated chronic diseases including diabetes and high blood pressure that cause kidney damage over time
Trauma including injuries to the kidneys or arteries that supply blood to the kidneys
Urinary tract obstructions including kidney stones, tumors, congenital deformities, and enlarged prostate glands
Ask your doctor about all of your treatment options and consider getting a second opinion before deciding on AV fistula surgery.
Who performs arteriovenous (AV) fistula surgery?
A general surgeon or vascular surgeon performs arteriovenous (AV) fistula surgery. A general surgeon specializes in the surgical treatment of a wide variety of diseases, disorders and conditions. A vascular surgeon specializes in surgery of the blood vessels.
How is arteriovenous (AV) fistula surgery performed?
Your arteriovenous (AV) fistula surgery will be performed in a hospital or outpatient surgery center. Surgeons usually create AV fistulas on the inner or palm side of the wrist or elbow.
Your surgical team will clean the surgical site and start anesthesia. Your surgeon will make an incision and attach an artery to a vein with stitches. Your surgeon will restore blood flow through the blood vessels once they are completely connected and close the incision with stitches. The AV fistula will become larger and tougher as it heals over several months. It will tolerate multiple needle punctures that are needed for dialysis.
Types of anesthesia that may be used
Surgeons often perform AV fistula surgery using local anesthesia while the patient is sedated. Local anesthesia involves injecting an anesthetic in the skin and tissues around the surgery area to numb the area. You may have another form of anesthesia, depending on your condition:
General anesthesia is a combination of intravenous (IV) medications and gases that put you in a deep sleep. You are unaware of the procedure and do not feel any pain.
Regional anesthesia is also known as a nerve block. It involves injecting an anesthetic around certain nerves to numb a large area of the body. You will likely have sedation with regional anesthesia to keep you relaxed and comfortable.
What to expect the day of your AV fistula surgery
The day of your AV fistula surgery, you can generally expect:
To talk with a preoperative nurse. The nurse will perform an exam and ensure that all needed tests are in order. The nurse can also answer questions and will make sure you understand and sign the surgical consent form. It is important to verify the correct surgical site with the operating staff.
To remove all clothing and jewelry and dress in a hospital gown. It is a good idea to leave all jewelry and valuables at home or with a family member. Your care team will give you blankets for modesty and warmth.
To talk with the anesthesiologist or nurse anesthetist about your medical history and the type of anesthesia you will have.
A surgical team member will start an IV.
The anesthesiologist or nurse anesthetist will start your anesthesia.
A tube may be placed in your windpipe to protect and control breathing during general anesthesia. You will not feel or remember this or the surgery as they happen.
The surgical team will monitor your vital signs and other critical body functions. This occurs throughout the procedure and your recovery until you are alert, breathing effectively, and all vital signs are stable.
What are the risks and potential complications of arteriovenous (AV) fistula surgery?
As with all surgeries, arteriovenous (AV) fistula surgery involves risks and potential complications. An AV fistula generally lasts longer and has fewer complications than other dialysis access options, such as a venous catheter or AV graft. Complications are still possible and may become serious or life threatening in some cases.
Complications can occur during surgery, throughout your recovery, or later after the AV fistula has been used for years of dialysis.
General risks of surgery
The general risks of surgery include:
Anesthesia reaction, such as an allergic reaction and problems with breathing
Bleeding, which can lead to shock or require blood transfusions
Blood clot, particularly a deep vein thrombosis (a clot that develops in the leg or pelvis). A blood clot can travel to your lungs, heart or brain and cause a pulmonary embolism, heart attack, or stroke.
Infection and septicemia, which is the spread of a local infection to the blood
Potential complications of AV fistula surgery
Complications of AV fistula surgery include:
Blood clot that develops in the AV fistula and blocks the flow of blood
Failure of the fistula
Infection of the fistula or skin and tissues around it
Reducing your risk of complications
You can reduce the risk of some complications by following your treatment plan and:
Checking the pulse in the access every day and notifying your doctor right away of any changes
Following activity, dietary and lifestyle restrictions and recommendations before surgery, during recovery, and as long as you need the AV fistula for dialysis
Informing your doctor or radiologist if you are nursing or if there is any possibility that you may be pregnant
Keeping the AV fistula site clean at all times
Not allowing healthcare personnel to draw blood or take blood pressure readings from the AV fistula arm
Not constricting the arm by sleeping on it or wearing tight jewelry or clothing
Notifying your doctor right away of any concerns, such as bleeding, fever, increase in pain, or wound redness, swelling or drainage
Protecting the AV fistula from injury and not lifting heavy objects with the AV fistula arm
Taking your dialysis treatments and medications exactly as directed
Telling all members of your care team if you have any allergies
Wearing a medical alert bracelet or tag that states you have kidney failure and an AV fistula. It should include the location of the AV fistula.
How do I prepare for my arteriovenous (AV) fistula surgery?
You are an important member of your own healthcare team. The steps you take before surgery can improve your comfort and outcome.
You can prepare for arteriovenous (AV) fistula surgery by:
Answering all questions about your medical history and medications. This includes prescriptions, over-the-counter drugs, herbal treatments, and vitamins. It is a good idea to carry a current list of your medical conditions, previous surgeries, medications, and allergies at all times.
Getting preoperative testing as directed. Testing varies depending on your age, health, and type of anesthesia. Testing may include blood tests, special kidney tests, a chest X-ray, EKG (electrocardiogram), and other tests as needed.
Losing excess weight before the surgery through a healthy diet and exercise plan
If you have high blood pressure, talk to your doctor about how to control it before and after surgery. Good blood pressure control can help decrease your risk of complications with AV fistula surgery.
Not eating or drinking just prior to surgery as directed. Your surgery may be cancelled if you eat or drink too close to the start of surgery because you can choke on stomach contents during anesthesia.
Stopping smoking as soon as possible. Even quitting for just a few days can be beneficial and help the healing process.
Taking dialysis treatments and medications exactly as directed
Questions to ask your doctor
Facing surgery can be stressful. It is common for patients to forget some of their questions during a doctor’s office visit. You may also think of other questions after your appointment. Contact your doctor with concerns and questions before surgery and between appointments.
It is also a good idea to bring a list of questions to your preoperative appointments. Questions can include:
Why do I need AV fistula surgery? Are there any other options for creating a dialysis access?
How long will the surgery take? When can I go home?
What restrictions will I have after the surgery? When can I return to work and other activities?
What kind of assistance will I need at home?
How do I take care of my AV fistula?
When will I start dialysis treatments using the AV fistula? How often will I need them?
How do I take my medications?
How will you treat my pain?
When should I follow-up with you?
How should I contact you? Ask for numbers to call during and after regular hours.
What can I expect after my arteriovenous (AV) fistula surgery?
Knowing what to expect can help make your road to recovery after arteriovenous (AV) fistula surgery as smooth as possible.
How long will it take to recover?
You will stay in the recovery room after surgery until you are alert, breathing effectively, and your vital signs are stable. You may have a sore throat if a tube was placed in your windpipe during surgery. This is usually temporary, but tell your care team if you are uncomfortable.
AV fistula surgery is often an outpatient procedure, so you go home the same day. Some patients stay in the hospital for other kidney failure treatments. Your surgeon will determine how long you need to stay in the hospital or outpatient center based on your age, condition, and medical history.
Recovery after surgery is a gradual process. Your arm may be sore for several days after surgery. Recovery time varies depending on the procedure, your general health, age, and other factors.
It generally takes several months for the AV fistula to heal, enlarge and develop enough for dialysis access. Once healed, you will see the thickened vein that is joined to an artery and feel a pulse in it. In the meantime, you may have dialysis treatments using a temporary venous catheter. This is a tube in your upper chest that connects the dialysis machine to your blood vessels.
Will I feel pain?
Pain control is important to healing and a smooth recovery. There will be discomfort after your surgery. Your doctor will treat your pain so you are comfortable and can get the rest you need. Call your doctor if your pain gets worse or changes in any way because it may be a sign of a complication.
When should I call my doctor?
It is important to keep your follow-up appointments after surgery. Contact your doctor for questions and concerns between appointments. Call your doctor right away or seek immediate medical care if you have:
Breathing problems, such as shortness of breath, difficulty breathing, labored breathing, or wheezing
Change in alertness, such as passing out, dizziness, unresponsiveness, or confusion
Chest pain, chest tightness, chest pressure, or palpitations
Fever. A low-grade fever (lower than 101 degrees Fahrenheit) is common for a couple of days after surgery and not necessarily a sign of a surgical infection. However, you should follow your doctor's specific instructions about when to call for a fever.
Leg pain, redness or swelling, especially in the calf, which may indicate a blood clot
Loss or change in the pulse in the AV fistula
Pain that is not controlled by your pain medication
Unexpected drainage, pus, redness or swelling of your incision
How might AV fistula surgery affect my everyday life?
AV fistula surgery can improve the comfort and quality of life for people who need long-term dialysis. An AV fistula is the preferred method of vascular access for long-term dialysis. It generally lasts longer and has fewer risks and complications than other access methods, including venous catheters and AV grafts.
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- Arteriovenous fistula. Encyclopedia of Surgery. http://www.surgeryencyclopedia.com/A-Ce/Arteriovenous-Fistula.html.
- Guidelines for Vascular Access. National Kidney Foundation. http://www.kidney.org/professionals/kdoqi/guidelines_updates/doqiupva_i.html.
- Hemodialysis Access: What You Need to Know. National Kidney Foundation. http://www.kidney.org/atoz/pdf/va.pdf.
- Manual of Anesthesia Practice: Upper Extremity AV Fistula Placement. Anesthesiacentral. http://anesth.unboundmedicine.com/anesthesia/ub/view/The-Manual-of-Anesthesia-Practice/102604/all/Up....
- Vascular Access for Hemodialysis. National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC). http://kidney.niddk.nih.gov/kudiseases/pubs/vascularaccess/.