Академический Документы
Профессиональный Документы
Культура Документы
Powered by JRank
Encyclopedia of
Surgery
Surgery » A-Ce » Arteriovenous Fistula
Arteriovenous fistula
Definition
An arteriovenous fistula (AV fistula) is the connection of a vein and an artery, usually in the forearm, to
allow access to the vascular system for hemodialysis, a procedure that performs the functions of the
kidneys in people whose kidneys have failed. Connecting the vein and artery is a surgical procedure. The
fistula develops over a period of months after the surgery.
Purpose
The surgical creation of an AV fistula provides a long-lasting site through which blood can be removed
and returned during hemodialysis. The fistula, which allows the person to be connected to a dialysis
machine, must be prepared by a surgeon weeks or months before dialysis is started. When the vein and
artery are joined, the vein gradually becomes larger and stronger, creating the fistula that provides
vascular access years longer than other types of access and with fewer complications.
Sometimes dialysis is only needed temporarily, but some people need it for the rest of their lives or until a
kidney is available for a transplant. When kidney failure is diagnosed, time is needed to prepare the
patient's body with either an AV fistula or implantable devices that will connect the person to the dialysis
machine.
Demographics
At any one time, the number of patients in the United States with kidney failure is approximately two
million and rising. According to the National Kidney Foundation, by the year 2008, three million people
will be expected to have what is known as end-stage renal (kidney) disease. These people can be of any
age, from any background. They are typically suffering from another condition or disease that has led to
kidney shutdown, and most will require dialysis. Among dialysis patients, over half will have an AV fistula
as vascular access.
Description
Many advances in the treatment of kidney failure have been seen since the first attempts at dialysis
treatments were made in the 1920s. At one time dialysis was only thought of as a way to keep people alive
until kidney function could be restored. Often the treatment for kidney failure had to be discontinued
within several days because patients' veins could not endure the trauma of frequent withdrawing and
replacing blood. The first breakthrough came in 1960 with the introduction of an implantable Teflon tube,
called a shunt, that was the first effective vascular access device. Since then, the development of the AV
fistula has marked another important advance, allowing effective treatment for longer periods of time.
The goal of researchers and medical institutions is to continue to improve treatment and improve the
length and quality of life for people with chronic kidney failure.
The kidneys are two organs in the mid-abdomen, one on each side of the middle back. Their function is to
clean the blood of wastes and regulate fluid and chemical balance in the body. Dialysis performs these
functions in place of the failing kidneys. Dialysis cannot restore the kidneys, but it can prolong life, often
for years, by preventing the build-up of waste products in the body. Acute kidney failure can happen in
many conditions and diseases that place an extra burden on the renal system, such as in advanced kidney
and liver diseases; in rapidly progressing terminal illnesses, such as cancer and certain severe anemias;
after severe allergic reactions or reactions to drugs or medications; in diseases that involve the vascular
system, such as heart and lung diseases or the formation of blood clots (embolism); and often following
heart bypass surgery. Diabetes and vascular diseases, especially those with hypertension (high blood
pressure), are the two most common underlying diseases contributing to chronic kidney failure.
Hemodialysis
Dialysis is performed as critical life support when someone suffers acute or chronic kidney failure. It is a
mechanical way to cleanse the blood and balance body fluids and chemicals when the kidneys are not able
to perform these essential functions. Because kidney function can be reversible in some cases, dialysis can
provide temporary support until renal function is restored. Dialysis may also be used in irreversible or
chronic kidney shutdown when transplantation is the medical goal and the patient is waiting for donated
kidneys. Some critically ill patients, with life-threatening illnesses, such as cancer or severe heart disease,
are not candidates for transplantation and dialysis may be the only option for treating what is called end-
stage renal disease (ESRD).
There are two types of dialysis, hemodialysis and peritoneal dialysis. In hemodialysis, the blood circulates
through a machine outside the body and is filtered as it circulates. In peritoneal dialysis, the blood is
filtered through a membrane that has been placed in the abdomen. Blood remains in the body and waste
material is filtered into an exchange fluid through an opening in the abdomen called a port. Only
hemodialysis requires an AV fistula or other vascular access.
Hemodialysis circulates blood through a dialysis machine that contains a filter membrane. The blood is
slowly pumped out of the body and into the machine for filtering. After being filtered, the blood is
returned to the body through the same vascular access. About one cup of blood is outside the body at any
given moment during the continuous circulation process.
Hemodialysis is usually done three times a week, taking between three and five hours each time.
Healthcare professionals perform the procedure either at independent dialysis centers or in hospitals or
medical centers. Dialysis patients must go to the hemodialysis center where they will sit to receive the
treatment. Although they cannot walk around, they can watch television, read, or talk to other patients.
The dialysis center offers patient education, including videos and brochures that describe treatment
options and self-care. Patients can also be given advice and information about paying for this ongoing
treatment through nationally sponsored programs that are available especially for dialysis patients. Often
the dialysis center offers emotional support as well, letting people meet and talk with other people who
have kidney problems. Some people prefer to perform their own dialysis by having a home dialysis
machine. This requires that the dialysis patient and another person, usually a family member, take a
three- to six-week training program to learn how to do the treatment.
Vascular access
An access or entry to the vascular system is needed to perform the blood-cleansing role of the kidneys
through hemodialysis. There are three types of vascular access: arteriovenous fistula, grafts, and
catheters.
ARTERIOVENOUS FISTULA. An AV fistula has proven to be the best kind of vascular access for people whose
veins are large enough, not only because it lasts longer but it is also less likely than other types of access to
form clots or become infected. If the veins are not large enough, or there is no time to wait for a fistula to
develop, a graft or a catheter must be used.
GRAFT. Grafts are often the access of choice when a hemodialysis patient has small veins that will not
likely develop properly into a fistula. This type of access uses a synthetic tube implanted under the skin of
the arm that can be used repeatedly for needle placement. Unlike a fistula, which requires time to develop,
a graft can be used as soon as two to three weeks after placement. Grafts are known to have more
problems than fistulas, such as clots and infection, and will likely need replacement sooner.
CATHETER. A catheter may be used to provide temporary vascular access. When kidney disease has
progressed quickly, there may not be time to prepare permanent vascular access before dialysis
treatments are started. The catheter is a tube that is inserted into a vein in the neck, chest, or in the leg
near the groin. Two chambers in the tube allow blood to flow in and out. Once the catheter is in place,
needle insertion is not necessary. Catheters are effective for dialysis for several weeks or months while
surgery is performed and an AV fistula develops. They are not selected for permanent access because they
can clog, become infected, or can cause the veins to narrow. Long-term catheter access must be used in
patients for whom fistula or graft surgery has not been successful. If more than three weeks' use is
expected, catheters can be made to tunnel under the skin, which increases comfort and reduces
complications
Diagnosis/Preparation
Diagnosis
The diagnosis of kidney disease and its progression to kidney failure is typically made by a nephrologist, a
specialist in kidney structure and function. The nephrologist will determine whether the patient has acute
or chronic kidney failure and if dialysis is appropriate for the patient. If dialysis is recommended, the
nephrologist will determine if an AV fistula is the ideal vascular access for the patient. To make these
determinations, the nephrologist will need to be aware of the patient's general condition, especially the
presence of any underlying disease. Kidney function must be evaluated and determined to be seriously
impaired before dialysis is recommended. It is typically started when kidney function is down to about
10% of its normal level. Among other tests that will be performed, such as urinalysis with microscopic
examination of the urine, several blood and urine tests can be used to measure a person's kidney function
when chronic or acute kidney failure is suspected. Some of the tests measure chemicals produced by the
body that are normally excreted (passed in urine) by the kidneys; the tests can measure how much is
passing through, and how much remains in the blood, and then determine how well the kidneys are
functioning compared to normal. These tests include, but are not limited to:
Description
Surgery to create an arteriovenous fistula is usually conducted using a local anesthetic, injected at the site
of the proposed fistula. The procedure is performed in a hospital or one-day surgery center and can
usually be performed on an outpatient basis if the patient is not already hospitalized. After cleaning and
sterilizing the site, the surgeon will make a small incision in the forearm sufficient to allow the permanent
joining together of a vein and an artery in the arm. The blood vessels will be appropriately blocked to stop
blood flow for the procedure and incisions will be made to join them. Silk sutures, just as those used in
other types of surgical incisions, will be used to close incised areas as needed after the vein and artery
have been joined. Once joined, blood flow will increase, the vein will become thicker, and over a period of
months the connection will become strong and develop into the fistula that will allow permanent vascular
access.
Aftercare
The hemodialysis patient should expect needle insertion in the AV fistula at every dialysis session.
Patients who prefer to insert their own needles or who perform dialysis at home will need training, and all
patients will have to learn how to avoid infection and to protect vascular access. Because vascular access
problems can lead to treatment failure, the AV fistula requires regular care to make dialysis easier and to
help avoid clots, infection, and other complications. Patients can help protect the access by:
There are other complications from dialysis that are not directly related to the vascular access. For
example, when the kidneys have shut down, they produce very little urine. Because dialysis is the only way
people with kidney failure can balance fluid levels in their bodies, hemodialysis can cause bloating and
fluid overload, indicating that too much fluid remains in the body. If fluid overload occurs, the patient will
have swollen ankles, puffy eyes, weight gain, and shortness of breath. Fluid overload can cause heart and
circulatory problems and fluctuations in blood pressure. Medications may be prescribed and changes in
fluid intake or diet may be made to help balance fluids safely in conjunction with dialysis.
Low blood pressure, if fluid and wastes are removed from the blood too quickly.
Nausea, because of changes in blood pressure.
Muscle cramps from the removal of too much fluid from the blood.
Headaches near the end of a dialysis session, due to changes in the concentration of fluid and
waste in the blood.
Fatigue after treatment, lasting sometimes into the next day.
Normal results
An AV fistula can usually be created and can function well with no adverse affects in a person whose veins
are large enough. The amount of time, usually a matter of months, it takes to develop the fistula after
surgery will depend upon the size and strength of the patient's blood vessels and on the person's general
condition and nutritional status. When the fistula develops, the thickened vein that has been joined to an
artery can be seen in the arm and a pulse can be felt. The early development of an AV fistula as access for
long-term dialysis has been shown to improve the survival of patients with chronic renal failure, and
reduce the chances of being hospitalized with complications. It also gives them a better opportunity to
choose self-dialysis as their treatment.
With good nutrition and a fully functioning AV fistula, dialysis patients can be relatively comfortable and
free of complications. People may become tired and uncomfortable when it is nearly time for their next
dialysis session. This is to be expected because wastes are building up in the blood, and the body senses
that it is time to remove them.
Kidney failure is reported to account for 1% of hospital admissions in the United States. It occurs in 2–5%
of patients hospitalized for other conditions, surgeries, or diseases. In patients undergoing cardiac bypass
surgery, 15% are reported to require dialysis for kidney failure. Overall deaths in people undergoing
dialysis are reported to be 50% because of the multi-organ dysfunction that has influenced kidney failure.
Resources
ORGANIZATIONS
National Kidney Foundation, Inc. 30 East 33rd Street, New York, NY 10016. (800)622-
9010. http://www.kidney.org .
National Kidney and Urologic Diseases Information Clearinghouse. 31 Center Drive, MSC 2560 Building
31, Room 9A-04, Bethesda, MD 20892-2560. (800)891-5390. http://www.niddk.nih.gov .
OTHER
Getting the Most From Your Treatment: What You Need To Know About Hemodialysis Access. Booklet.
New York: National Kidney Foundation, Inc. (800)622-9010. http://www.kidney.org .
NIDDK Kidney Failure Series. Booklet. Bethesda, MD: National Kidney and Urologic Diseases
Information Clearinghouse. Email: nkudic@info.niddk.nih.gov.
Vascular Access to Hemodialysis. National Kidney and Urologic Diseases Information Clearinghouse,
Home Health Information. December 1999.http://www.niddk.nih.gov .
L. Lee Culvert
The surgery to create an arteriovenous fistula for vascular access in hemodialysis is performed by a
general surgeon or vascular surgeon in a hospital or one-day surgery center. It requires only local
anesthesia and can be performed as an outpatient procedure.
User Contributions:
1
Aseem Mishra
2
Dr. Tom M. Omulo
4
whitney
5
EEvita
6
D. Satheesh Kumar
7
David C. Untalan Jr.
8
Manish Kanchhal
9
R.ASWIN KUMAR
11
Michelle
12
dr nazrul
13
Kathleen
14
Nicole
15
john barnes
16
dr saher saadi
Apr 10, 2010 @ 1:01 am
I am nephrology physion since 1994 -also i interest in this field where we face daily problems in this programm
and i need more information and practical veiw on it.
thank u
Dr.saher
head of 2-march hemodialysis center
tripoli libya
17
Ron Loeffler
Thank you.
18
Lieberman,Ira
19
Sonya Stewart
20
mohamed
21
Dr Kishwar
22
Paula
Jul 15, 2010 @ 9:09 am
I have had an AV Fistula now for 26yrs and have had no problems with it apart from it becoming larger over the
yrs ... i have been advised to have it removed as i have not on dialysis now for 26yrs ( was on dialysis for a short
period only 4mths) its a gr8 party trick :)
23
Alan
24
Brian
25
nikki
26
bessy
27
Jose
28
peggy
29
just mom
30
susmitha
31
jain
32
Dave
33
Ma. Elaine Mariz Calabia
34
raymund
35
ansari
36
Jean
37
vonna
38
Gucci
39
theja
40
Keiko Omori
41
donna
42
Lydia Cota
43
Efrain
44
Mike
They used it so soon as most of them says it's too troublesome having 2 entry points vide perm cath & AVF.
45
A-Razaque Ahmes
46
Kirk Blackwell
Aug 20, 2012 @ 7:19 pm
Should an AVF be put on the same side of the patient that has a pacemaker defibrillator and a synchronizer. My
father had this done an he has had very bad swelling in arm since surgery . We have been told in so many words
that it probably should have been put in other arm. What should our next step be to correct this problem?
t
Thanks!
47
Richard Patterson
48
Richard Patterson
49
Debi Willoughby
50
Michael Knight
51
Carol
52
Dr. M.A.Jaffer
Mar 30, 2013 @ 3:03 am
I would like to know what is the average logitivity of the AVF when primary , and what is it if a graft is used.
thanks
53
Phindile P
54
Tim
55
Marie-France
Comment about this article, ask questions, or add new information about
this topic:
Name:
E-mail:
Send