Ateriovenous Fistula

for Hemodialysis
Types of conduits and case study
Fundamentals
An ateriovenous fistula (AVF) is a surgically made connection
between an artery and a vein as to be used as a conduit for
hemodialysis

An AVF is a necessity for patients that have kidney failure in
order to filter blood to remove toxins and extra fluid

During dialysis two needles are inserted into the fistula, one
draws blood from the vessel and transfers it to a dialysis
machine, in which blood is circulated and filtered then returned
back to the blood stream through the second needle
Types of fistulas
Radial-cephalic
anatomical snuffbox, wrist,
direct or transposed or straight
The advantages are larger
vessel size, simplicity of
anastomosis and lower risk of
ischemic complications. The
fistula can be done via various
construction configurations, the
most common is side-to-side
and end vein to side artery


Types of fistulas
Brachial-cephalic
The cephalic vein is
anastomosed to the
brachial artery just distal
to the antecubital
crease by using: an
antecubital vein or the
cephalic vein itself
Types of fistulas
Brachial-basilic transposition
The basilic vein is routinely
transposed because there is
only a short segment above
the antecubital crease
superficial enough for easy
cannulation before the vein
runs deep to the fascia
Types of arteriovenous grafts
Upper arm straight graft
Straight AVG in the upper
arm between the brachial
artery and the axillary vein
(or the proximal brachial or
basilic vein) is ideal and
common
Types of arteriovenous grafts
Forearm loop graft
The forearm loop
between the brachial
artery and one of the
available veins in the
antecubital fossa
Types of arteriovenous grafts
Lower extremity grafts
Either vein or synthetic
AVFs in the lower
extremity are generally
reserved for patients
whom have exhausted
arm sites. Leg fistulas are
rare due to reasons of
higher rates of infection
and ischemia, as well as
the need to preserve the
saphenous veins for
coronary artery bypass
and other bypass
procedures
Femoral loop graft Femoral straight graft
Case study
Arteriovenous fistula stenosis
History
Left basilic transposition created September 2013
55 year old male
Left arm access slightly pulsatile
Bruit present
Questionable outflow stenosis

Following procedures:
Ultrasound examination
Balloon angioplasty


January ultrasound exam results
INTERPRETATION:
1) Unusually high velocity in the axillary vein, above the
basilic/axillary vein confluence on the left, reaching
459/284cm/sec. The preoperative vein mapping examination
identified a high velocity and abnormal diameter at this site in the
axillary vein. However, diameter measurements are not as small at
this time. Based on the velocity there is a moderate-severe stenosis
in the axillary vein.
2) Velocities are elevated in the arterial and venous ends of the
access in the left arm consistent with a mild-moderate stenosis.
January operative results

Mild-Moderate stenosis arterial end of AVF
Severe stenosis at axillary/basilic confulence
Severe stenosis at axillary/basilic confulence
After angioplasty utilizing
a 7mm x 4cm balloon
New symptoms arise in April
AVF has decreased thrill, resistive bruit at origin, decreased
filling of proximal AVF
Dysfunction on hemodialysis
Ultrasound ordered for evaluation for restenosis

Following procedures:
Ultrasound examination
Balloon angioplasty
April ultrasound exam results
LEFT UPPER ARM:
There is a severe acceleration in the velocity 1.0cm above the inflow
anastomotic site and again high in the arm at the confluence with the
axillary vein. Velocities are 720/442cm/sec and 531/412cm/sec
respectively. The remainder of the access is unremarkable.

INTERPRETATION:
1) Severe stenosis of the left upper arm dialysis access fistula 1.0cm
above the inflow anastomotic site.
2) Severe stenosis high in the left arm at the access with the axillary vein.


May operative results
Severe stenosis
1cm above inflow anastamosis
Severe stenosis arterial end of AVF
Severe stenosis arterial end of AVF
Severe stenosis at confluence
Severe stenosis at confluence
Comparision of restenosis areas
Balloon angioplasty is a good resolution for a
dysfunctional arteriovenous fistula for
continued effective use
Areas of significant stenosis in arteriovenous
fistulas have a much higher rate of restenosis
in the same locations of prior stenoses.
The following images show the stenoses prior
to balloon angioplasty and the restenosis 3
months after the procedure
January 2014

Mild-Moderate








April 2014

Severe
January 2014

Mod-Severe








April 2014

Severe
References
Alwakeel, H., & Elalfy, K. Vascular Access for Hemodialysis- How to Maintain in
Clinical Practice. , Chapter 28. Retrieved January 1, 2014, from
http://www.intechopen.com/books/export/citation/EndNote/hemodialysis/vascula
r-access-for-hemodialysis-how-to-maintain-in-clinical-practice

Gerald, B. (2010, January 1). A Practitioners Resource Guide To Hemodialysis
Arteriovenous Fistulas. . Retrieved January 1, 2014, from
http://www.esrdnet15.org/QI/C5E.pdf