Diagnosis
When a person’s kidneys fail, dialysis is often required if transplantation cannot be performed. Dialysis can be performed using the abdominal cavity (peritoneal dialysis) or by filtering the blood. In turn, blood for filtration can be obtained via a catheter or arteriovenous fistula (AV fistula). Catheters can be placed on short notice but have a short usable life-span and are difficult to care for. By contrast, a fistula requires surgery and cannot be used until they heal, but can last for years. Your nephrologist has recommended hemodialysis via a surgically constructed AV fistula.
Many types of fistulas are possible, but it is best to use your own veins and arteries and stay as far out on the arm as possible. The purpose of today’s visit is to discuss the mechanics of surgery and to identify the best possible site(s) for fistula creation, as well as to discuss tentative plans for future fistulas.
Today’s Visit
We will perform ultrasound testing if data do not already exist. We will also discuss your medical history, the details of your situation, and fistula options in better detail.
What You Can Do
Once we have agreed on a plan, do not let anyone put any needle into the arm that we are “saving” for the fistula. This includes IVs and blood drawing, but checking blood pressure is fine.
Surgery
Many types of fistula merely require moving a vein over to an adjacent artery, which necessitates only a small incision. If a basilic transposition is recommended, this will require a more extensive incision along your upper arm. In almost all cases this is an ambulatory procedure, with discharge to home planned several hours after the procedure. Most cases can be performed under local anesthetic. Very rarely, an artificial graft or fistula in the leg is recommended.
It should be stressed that the vein has to enlarge enough to be used; such maturation of the fistula usually takes about 6 weeks. Fistulas mature about 75% of the time; thus in a quarter of cases the fistula never works and another operation is required. In addition, minor operations to correct local narrowing in the vein are sometimes needed. Finally, while a good fistula can last for years, they never last forever. Creation and maintenance of reliable access for dialysis is an ongoing process and patience is required from patient, family, and surgeon.
After Surgery
If all goes well, you will go home several hours after surgery. At home, you can gradually resume normal activities as tolerated, but should work up to things slowly. You will be sore and should plan to have someone at home with you to help with meals, house keeping, grocery shopping, and so on, for the first few days or so. You may have a drain; we will give you appropriate instructions and make arrangements for removal. You may remove your dressings and shower/wash the second day after surgery unless other instructions have been given or you still have a drain. You will see your surgeon 2 weeks after discharge for routine follow-up, and 6 weeks after surgery to check the fistula with ultrasound. Once the fistula is functional, we will remove your catheter, if present. We will usually recommend lifelong visits to check the fistula at 6-month intervals.