Arteriovenous Fistula (AVF) : Maj Rashed Ashraf FCPS P-II Trainee Department of Anaesthesiology CMH Dhaka

Arteriovenous Fistula (AVF)
Maj Rashed Ashraf

FCPS P-II trainee
Department of Anaesthesiology
CMH Dhaka
Arteriovenous fistula (AVF)
Subcutaneous anastomosis (communications) of an artery to a vein,

allowing blood flow directly moves from artery to vein.
 AVF is a continuous circuit (not only anastomosis).
 Starts at the heart and ends at the heart.
 Usually the anastomosis is made at the wrist between

the radial artery and the cephalic vein.
Indication
Hemodyalysis
Advantages of AVF
Lower risk of infection
Lower tendency to clot > fewer secondary interventions
Lower hospitalization rates (lower complication rates ,lower
morbidity and mortality)
 Allows for greater blood flow
Long-term patency (improved performance with
time)
Less cost of implantation and maintenance.
Disadvantages of AVF
 Slow maturation and failure of maturation.
 More difficult to needle.
 Cosmetic appearance of dilated veins.
 Increase in size with age and aneurysm formation.
Vascular anatomy of upper limb
Basilic vein: drain medial side of upper limb

Cephalic vein: drain lateral side of upper limb
Types of common arteriovenous fistula
according to its site in the upper limb
1. Radial–cephalic AV fistula ( wrist )
2.Brachial–cephalic AV fistula
(elbow)
3.A transposed brachial basilic vein fistula
16
Care of AVF
We should not insert peripheral IV catheters or cardiac
pacemaker
 We should not use for blood draws or IV drugs
 We should not use for taking blood pressure or try any surgical
procedures
Patient Education (Daily Care)
Good fistula care will help maintain the patency of the vascular access.
Check the thrill at least once daily
Avoid tight clothing , jewellery or watch
Avoid carrying heavy object
Avoid exposure to extremes of heat/cold

 Avoid check BP, venipuncture or IV drugs sleeping on
the access arm
 Use the access site only for dialysis
 Wash the access with soap and water pre-dialysis

 Look for signs of infection (pain, swelling, redness…….)
 Absence of thrill must be reported to the renal unit.

Maturation
The fistula may need 6-8 weeks to mature and ideally ≥12
weeks.
Cannulation is one of the primary causes of AVF failure
Sequences of needle punctures into the vessel wall >>

 Endothelial injury leukocyte adhesion migration
of smooth muscle cells from the media to the intima and
proliferation.
 Intimal hyperplasia thickening of the vessel wall
venous stenosis (main cause of access failure).
 Infiltration, aneurysms and hematoma needle induced
vessel injury

Fistula maturation
Rule of 6's
Time:6 weeks old

Depth:6 mm deep
Diameter: 6 mm fistula diameter
Flow:600mL per min flow

24
Complications of fistula
 Aneurysm , Pseudo aneurysm
 Infection
 Thrombosis (clotting)
 Bleeding
 Infiltration & Hematoma
 Poor arterial flow and increased venous
 Stenosis
 High output heart failure
Aneurysm
 A consequence of an AV fistula creation is thickening and
enlargement of the vein walls due to arterialization.

Infection
AV fistulas have lowest risk of infection of any vascular
access type.
Causes
Inadequate disinfection of the skin
Contamination of the needle
Manipulation of the needle during dialysis
Scratching of the puncture site
Poor personal hygiene
Contamination due to bathing.
Thrombosis (clotting)
 The most common complications of AVF.
 Venous stenosis resulting in reduced blood flow, infection,

recirculation, damage to the vessel wall, and eventually clotting of
the fistula.
30
Causes
 Surgical/technical problems
 Preexisting anatomic lesions
 Premature use
 Poor blood flow or hypotension
 Hypercoagulation
 Fistula compression (Patientwhile
sleeping)
Bleeding
Causes
Bleeding after remove needle
Anticoagulation/not stopping prior to end of HD
Improper pressure with needle withdrawal

Infiltration & Hematoma
The pathological accumulations of substances in tissue or cells
which are normally are absent.
Causes:
An improper needle flip or taping procedure can cause an
infiltration.
 Hematoma
 If bruising or hematoma occurs after dialysis, the surface skin site

has sealed but the needle hole in the vessel wall has not.
 Use 2 fingers per site for hemostasis
 It is crucial to apply pressure to both the skin and

Poor arterial flow and increased venous
pressure
 May be due to location or position of needle
 May be there are thrombosis or stenosis or

significant recirculation.
 This poor flow may lead to clotting of the AVF

Stenosis
Most common complication
Hyperplasia in lumen (usually arterial side)
Frequent cause of fistula failure
Causes:
Surgery to create AVF
 Turbulence-Pseudoaneurysm-aneurysms
Needle-stick injury
Type of stenosis:
1. Juxta-anastomotic (most common stenosis in AVF)
2.Mid-access stenosis
3.Outflow stenosis
4.Central vein stenosis
Clinical feature of stenosis:
 Clotting of the extracorporeal circuit 2 or more

times/month
 Persistently swollen access extremity
 Changes in bruit or thrill (ie, becomes pulse-like)
 Difficult needle placement
 Blood squirts out during cannulation
 Elevated venous pressures
 Inability to achieve optimum blood flow rate.
 Recirculation
 Prolonged postdialysis bleeding
 Presences of frequent episodes of access clotting

Normal Stenosis
Thrill Only at the At site of
arterial stenotic
anastamosis lesion
Pulse Soft, easily Water-

compressible hammer
Bruit Low pitch, High pitch,

Continuous Discontinuous
Diastolic & Systolic only
systolic
Steal syndrome: Deprivation of blood distal to AVF.
Steal syndrome is ischemia of the hand
Inadequate blood supply to the hand, caused by the

AVF“stealing” blood away from the extremity, this causes
hypoxia (lack of oxygen) to the tissues of the hand resulting in
severe pain and neurologic damage to the hand can occur.
Risk factors
 Brachial arterial origin
 Diabetes mellitus
 Peripheral vascular disease (PVD)
 Female gender
Clinical Feature
 Most patients are asymptomatic

 Cold sensation and pale colour of the fingers
 Ischemic pain
 Diminished or absent pulses
 Capillary refill will decrease
 Neurological and soft tissue damage to the hand can occur,
resulting in mobility limitations (eg, grip strength, skill), loss of
function, ulcerations, necrosis
Diagnosis of Steal Syndrome
 Clinical investigation –Allen test.

 Noninvasive imaging tests: measurement of digital pressure
and access flow measurements.
 Angiography
 Pulses, BP, pulse oximetry,Doppler,duplex USG
Thank You
111

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Arteriovenous Fistula (AVF)

Maj Rashed Ashraf

Subcutaneous anastomosis (communications) of an artery to a vein,

 Starts at the heart and ends at the heart.

 Usually the anastomosis is made at the wrist between

Basilic vein: drain medial side of upper limb

 We should not use for blood draws or IV drugs

Check the thrill at least once daily

Avoid tight clothing , jewellery or watch

Avoid carrying heavy object

Avoid exposure to extremes of heat/cold

 Use the access site only for dialysis

 Wash the access with soap and water pre-dialysis

 Absence of thrill must be reported to the renal unit.

Sequences of needle punctures into the vessel wall >>

Time:6 weeks old

Diameter: 6 mm fistula diameter

Flow:600mL per min flow

 The most common complications of AVF.

 Venous stenosis resulting in reduced blood flow, infection,

 Preexisting anatomic lesions

 Poor blood flow or hypotension

Bleeding after remove needle

Anticoagulation/not stopping prior to end of HD

Improper pressure with needle withdrawal

 If bruising or hematoma occurs after dialysis, the surface skin site

 Use 2 fingers per site for hemostasis

 It is crucial to apply pressure to both the skin and

 May be there are thrombosis or stenosis or

 This poor flow may lead to clotting of the AVF

 Clotting of the extracorporeal circuit 2 or more

 Prolonged postdialysis bleeding

 Presences of frequent episodes of access clotting

Pulse Soft, easily Water-

Bruit Low pitch, High pitch,

Steal syndrome is ischemia of the hand

Inadequate blood supply to the hand, caused by the

 Brachial arterial origin

 Peripheral vascular disease (PVD)

 Most patients are asymptomatic

 Clinical investigation –Allen test.

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