Browse the corpus

Dialysis fistula creation is a commonly performed procedure for patients who suffer from the end-stage renal disease who require permanent vascular access for hemodialysis. Arteriovenous fistulas are the preferred initial access compared to prosthetic grafts or hemodialysis catheters. The most common arteriovenous fistula techniques include the radiocephalic fistula, brachiocephalic fistula, and transposed brachiobasilic fistula. This activity outlines the preparation and complications of dialysis fistula creation and highlights the role of the interprofessional team in evaluating and managing dialysis fistulas. Objectives: Identify the indications for dialysis fistula creation. Outline common complications of arteriovenous dialysis fistulas. Summarize the techniques involved in arteriovenous dialysis fistula creation. Explain the importance of improving care coordination among the interprofessional team to improve outcomes in patients with the end-stage renal disease with arteriovenous dialysis fistulas. Access free multiple choice questions on this topic.

Dialysis fistula creation is a commonly performed procedure for patients who suffer from end-stage renal disease (ESRD) who require permanent vascular access in order to receive long-term hemodialysis. The ideal dialysis fistula delivers a high flow rate sufficient for effective dialysis, is suitable for repeated cannulation, and has long-term patency rates with minimal complications.[1] According to the National Kidney Foundation, over 400,000 patients are treated with hemodialysis in the United States with medicare spending, on average, 90,000 USD per patient per year of treatment.[2] While there are various techniques for permanent dialysis access, arteriovenous fistulas (AVFs) are proven to have superior clinical and economic advantages. Guidelines from the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) and the Fistula First Initiative recommend that autogenous AVFs should be considered as the preferred initial access for hemodialysis in patients with ESRD, followed by prosthetic grafts, and finally hemodialysis catheters.[3] Studies have demonstrated a clinically significant decrease in the rate of infections, hospitalizations, catheter failure, central venous stenosis, and mortality, as well as overall cost with AVFs compared to prosthetic grafts or hemodialysis catheters.[4][5][6] Despite the prolonged maturation time that delays immediate use, patency rates for AVFs range from 3 to 5 years, compared to 1 to 2 years for AV grafts.[4] This article will discuss the relevant anatomy, indications, contraindications, procedure details, and complications associated with arteriovenous dialysis fistula creation.

As with any surgical procedure, there is a risk of bleeding, infection, or damage to surrounding structures. High-risk patients may be at increased risk for complications that may result in significant morbidity. Complications can be divided into immediate, early (days to months), or late (after maturity). Immediate Complications: Hematoma, bleeding, edema, ischemic steal syndrome, or loss of thrill secondary to acute thrombosis or intra-arterial flap Early Complications: Stricture, thrombosis, infection, venous hypertension, central venous stenosis, ischemic steal syndrome, or failure to mature Late Complications: Aneurysm, stricture, late thrombosis, infection, or neuropathy The most common dialysis fistula complications that may require intervention include aneurysm, infection, thrombosis, central venous stenosis, ischemic steal syndrome, and failure to mature.[9] Aneurysm: Repeated needle punctures in a centralized area can weaken the vascular access wall and cause aneurysm formation. Aneurysmal dilation can also occur over time due to high blood flow and be accelerated by elevated pressures within the fistula. Aneurysms generally require surgical repair if there is a loss of skin integrity, ulceration, or limited puncture sites available. High-risk aneurysms that are left untreated can result in rupture and fatal exsanguination.[9] Infection: Most AV fistula infections involve perivascular cellulitis presenting as erythema, edema, and possible systemic signs. Localized infections can be treated with appropriate antibiotics based on wound and blood cultures. More serious infections associated with aneurysm, hematoma, or abscess require surgical excision and drainage.[9] Thrombosis: Thrombosis is the most common fistula complication and occurs in areas of stenosis, either at the anastomosis or fistula vein. The risk of thrombosis increases with the degree of stenosis. Compared to AV grafts, fistulas have lower rates of thrombotic events.[9] Central Venous Stenosis: Venous hypertension can result from central venous stenosis and causes upper extremity swelling that may progress to decreased mobility. The most common cause of central venous stenosis is the placement of central venous catheters and devices. Central stenosis may present as reduced quality of dialysis, problems with cannulation, pain in the area of the fistula, or increased venous pressures.[3][9]

Central Venous Stenosis: Venous hypertension can result from central venous stenosis and causes upper extremity swelling that may progress to decreased mobility. The most common cause of central venous stenosis is the placement of central venous catheters and devices. Central stenosis may present as reduced quality of dialysis, problems with cannulation, pain in the area of the fistula, or increased venous pressures.[3][9] Ischemic Steal Syndrome: Steal syndrome is the result of decreased blood flow to the distal extremity after AV fistula creation. Clinically significant implications include pain, decreased motor function or sensation, or neuropathy. The rate of ischemic steal syndrome is decreased in forearm fistulas when compared to upper extremity fistulas. Furthermore, when compared to AV grafts, fistulas have a two-fold lower risk of developing steal syndrome.[9] Failure to Mature: One of the most common causes of failed maturation is due to anastomotic stricture caused by neointimal hyperplasia. Stricture is defined as a greater than 50% decrease in the luminal diameter of the outflow vein.[9] Risk factors that compromise AV fistula maturation include age greater than 65 years, an elderly patient with decreased vascular compliance, and comorbidities including hypertension, diabetes, obesity, heart failure, and peripheral atherosclerosis.[10] Surgical correction may be warranted, such as ligation of vein branches or revision of the anastomosis.

An interprofessional team approach is crucial to the success of dialysis fistula in ESRD patients and should involve collaboration between primary care physicians, nephrologists, vascular access surgeons, interventionalists, dialysis nurses, and vascular access coordinators. The primary care physician must actively screen patients for chronic kidney disease and intervene with timely referral to a nephrologist for evaluation and treatment. The nephrologist oversees the care of the patient to ensure appropriate dialysis care. Vascular surgeons must decide the placement and type of vascular access that will yield the greatest success rate. Given the high rate of vascular access dysfunction, interventionalists can play a critical role in the maintenance and restoration of dialysis access using endovascular techniques. The dialysis nurse plays a critical role in patient care as they can examine and monitor access three times per week during dialysis. Lastly, the vascular access coordinator is essential for organizing patient hemodialysis care.[6]

Communication and coordination between the interprofessional team are required to optimize vascular access outcomes as well as patient morbidity and mortality. Nursing staff must communicate effectively during handoff to report a history of end-stage renal disease and arteriovenous dialysis fistula. Nurses can help preserve veins for dialysis fistula creation by avoiding peripheral venous access, blood draws, or blood pressure measurements on the side of fistula planning. For nurses taking care of patients on the floor, it is paramount to learn how to assess for fistula thrill, differentiate thrill from pulsating fistulas, and identify loss of thrill. Understanding complications such as ischemic steal syndrome and patients complaining of numbness or tingling after dialysis can prompt nurses to call surgical services sooner. Dialysis nurses also play a critical role in evaluating and managing dialysis fistulas. Dialysis nurses can report arteriovenous fistula malfunction during dialysis, such as decreased flow rates (possible inflow or outflow obstruction), delayed hemostasis at needle puncture sites (possible outflow obstruction), or erythema and drainage overlying the fistula site (possible infection). Dialysis nurses can also convey difficult access due to fistula depth so that patients can undergo a procedure called superficialization if necessary.

Doppler Signal: Place the doppler probe over the fistula to obtain a signal. Doppler signals may be described as monophasic, biphasic, or triphasic. Thrill: Place the tips of the fingers lightly over the fistula. A thrill is a vibration felt over the fistula and implies patency. Pulsation: Place the tips of the fingers lightly over the fistula. Pulsation is a strong heartbeat felt over the fistula, which may indicate possible outflow stenosis. Overlying Skin Changes: Erythema, warmth, edema, or drainage may all be signs of possible fistula infection and can lead to loss of vascular access. These findings should be promptly reported to a physician. Bleeding: Continuous oozing at the cannulation site may suggest outflow stenosis or may be the result of coagulopathy secondary to uremia.