Basic

concept:
AV Fistula and AV graft

Yulia Wardhani
Divisi Ginjal & Hipertensi
DEPARTEMEN Penyakit Dalam
FK-UGM/RSUP Dr. Sardjito
Yogyakarta
Types of Hemodialysis Access

Fistula (arteriovenous fistula)

Graft (arteriovenous graft)

Catheter
 Figure 4.1 Vascular access use at hemodialysis initiation,
from the ESRD Medical Evidence form (CMS 2728), 2005-2013

Data Source: Special analyses, USRDS ESRD Database. ESRD patients initiating hemodialysis in 2005-2013. Abbreviations:
AV, arteriovenous; CMS, Centers for Medicare & Medicaid; ESRD, end-stage renal disease.

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Vol 2, ESRD, Ch 4
Figure 4.6 Trends in vascular access type use among ESRD prevalent patients,
2003-2014

Data Source: Special analyses, USRDS ESRD Database, and Fistula First data. Fistula First data reported from July 2003
through April 2012, CROWNWeb data are reported from June 2012 through December 2013. Abbreviations: AV,
arteriovenous; ESRD, end-stage renal disease.

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Vol 2, ESRD, Ch 4
Figure 4.7 Vascular access use during the first year of hemodialysis by time since
initiation of ESRD treatment, among patients new to hemodialysis in 2013, from
the ESRD Medical Evidence form (CMS 2728) and CROWNWeb data, 2013-2014

Data Source: Special analyses, USRDS ESRD Database. Medical Evidence form (CMS 2728) at initiation and CROWNWeb
for subsequent time periods. Abbreviations: CMS, Centers for Medicare & Medicaid; ESRD, end-stage renal disease.

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Vol 2, ESRD, Ch 4
What is Arterio-Venous fistula?
• AV fistulas and Grafts are the commonest form of vascular access
used to maintenance hemodialysis
• Surgically created “end to side” shunts which allow dialysis.
• An AV fistula involves creating an anastomosis between an artery
and a native vein, allowing the blood to flow directly from the artery
to the vein
• Lower arm (radio-cephalic) better than upper arm (brachio-cephalic,
brachio-basilic, brachio-brachial).
• It is done as minor outpatient surgery
• Usually take 6 to 8 weeks for mature
• During maturation process blood flow through the newly created
fistula will graduately increase due to dilatation both artery and vein.
Pressure and flow induced remodeling (thickening) of the wall of the
fistula vein
• Considered the best long-term vascular access because it provides
adequate blood flow, lasts a long time, and has a lower complication
rate than other types of access
What is Arterio-Venous graft?
• An AV graft is similar, except that the distance between the
feeding artery and vein is bridged by a tube made of
prosthetic materials.
• The most commonly used bridging material is
polytetrafluoroethylene (PTFE) polymer
• An AV graft can be used earlier than a fistula, generally
within 1-3 weeks after placement
AV Graft Diagram
AV Graft
• Usually only lasts 3-5 years
• More likely to get infected than AVF
• More likely to have blood clots than an AVF
• Longer bleeding time than an AVF after dialysis needles are
removed
• Need for endovascular interventions to maintain patency
Advantages of the AV Graft
• Large surface area for needle placement
• Easy cannulation
• Short maturation time
• Easy surgical handling characteristic
Neointimal hyperplasia
• AV graft is a less desirable access than AV fistula
• AV graft has higher risk of neointimal hyperplasia (most
commonly occur in venous segment downstream)
• Hyperplasia à obstruct the lumen à poor flow in the graft
à prolonged bleeding after dialysis (due to intragraft
pressure) à lead to graft thrombosis
Guideline Targetting AV Fistula First

• K/DOQI and “Fistula First” initiative promote construction of AV

Fistula
• Targetting at least 68% use in prevalent patients on dialysis
• Early referral of CKD patient to nephrologist prior to the start of
hemodialysis
• US : 26% à 61%
• Europe : > 90%
Arteriovenous Access Planning

Patient Patient with eGFR <30 ml/min/1.73m2 should be

education educated abaout RRT modality option
and
Timing AVF should be placed at least 6 months prior to te
panned of hemodialysis initiation
issues
Patient who are planning to receive live donor kidney in
the near future can be managed without a permanent AV
access
PREOPERATIVE EVALUATION

Patient history Physical examination Imaging studies

• Previous episodes of • All pulses (axillary, • Preoperative

CVC, cardiac brachial, radial, ulnar) mapping
implantable device, • Blood pressure in • Doppler US
vascular surgery both arms, difference • Venography
• Severe vascular MAP: • Arteriography
disease, • < 10 mmHg :
atherosclerosis, normal
diabetes • 10-20 : borderline
• > 20 : problematic
Doppler Ultrasonography
• Measure flow velocity
• Measure inner diameter of the brachial and radial arteries
and peripheral veins
• Identify suitable arteries and veins for access placement
Doppler Ultrasonography

Minimal vein and artery size Vein dilation test

Studies suggest for successful During the Doppler study the

fistula proximal vein is occluded using a
tourniquet and the increase in size is
Minimum vein lumen diameter recorded
2.5 mm (Okada and Shenoy, 2014)
Minimal arterial diameter 2.0 mm Average increase in internal
(Okada and Shenoy, 2014) diameter of 50% has been
associated with successful fistula
Venography Arteriography

Evaluating the central vein When pulses in desired access

location are diminished

History of transvenous >20 mmHg difference in mean

placement of pacemaker arterial pressure between the 2 arms

Physical finding of upper

extremity edema
Possible locations for upper extremity AV Fistulas

Conventional Snuff-box (distal-most site)

Radiocephalic or Brescia-cimin0 (at the wrist)

Ulnar artery to forearm basilica vein

Brachial artery to upper arm cephalic vein (at the

elbow)
Possible locations for upper extremity AV Fistulas

Transposed Foresrm basilic vein to radial artery at the wrist

Forearm basilic vein to brachial artery

Forearm cephalic vein to brachial artery

Transposed basilica vein in th eupper arm to brachial artery

Perforating vein in the proximal forearm to proximal radial artery

PERIOPERATIVE CARE AND FISTULA MATURATION

PERFORM ARM EXERCISE FOR SEVERAL WEEKS PRIOR TO SURGERY

FOLLOWING SURGERY
• The arm should initially be elevated
• Tight circumferential dressing should be avoided
• Hand exercise (squeezing a rubber ball, increasing fistula blood flow and pressure
• Should never be used for venipuncture
• Shoud be checked daily (feeling fo a thrill in the anastomotic site and by listening
for an associated bruit
 RULE OF SIXES
Maturation should occur by around 6 weeks after surgery

Vein diameter should be at least 6 mm

Include straight segment for cannulation at least 6 cm in length

Less than 6 mm below the skin

Have a blood flow at least 600mL/min

Typical AV Fistula

“Venous” needle

Thrill “Arterial” needle

Typical AV Fistula
Venous pressure

Arterial pressure
Problems with fistula
• Poor development
• Difficulty needling
• Inadequate dialysis
– Low flow rates
– Recirculation
• High pressures and prolonged bleeding
• Thrombosis
• Almost all due to stenoses which are recurrent
Flat AV Fistula: peri-anastomotic stenosis

“Venous” needle

Weak thrill “Arterial” needle

Pulsatile AV Fistula: stenosis away from anastomosis

Flat

Remote Thrill

Pulsatile and high pressure

Recirculation

Thrill

“Venous” needle

“Arterial” needle
Treatment options
• Angioplasty
– Standard balloon angioplasty
– High pressure balloon
– Cutting or scoring balloon
• Surgery
• Refashion anastomosis
• Patch stenosis
• Higher fistula