Arteriovenous fistula creation is a surgical procedure used to establish a permanent vascular access, specifically designed for patients with chronic kidney failure requiring long-term hemodialysis. This surgery directly connects a peripheral artery to a vein, causing the vein to dilate and thicken, making it suitable for repeated punctures as a dialysis access. This technique provides stable blood flow, ensuring smooth dialysis treatment.
The surgery is usually performed on the forearm, primarily involving an anastomosis between the autologous artery and vein, which can be either end-to-end or end-to-side. A successfully created fistula requires 4 to 8 weeks to mature before it can be used. This treatment effectively reduces the risk of infection associated with central venous catheters and enhances dialysis efficiency.
Arteriovenous fistulas are mainly divided into "autologous arteriovenous fistulas" and "synthetic graft fistulas." Autologous fistulas use the patient's own blood vessels, such as the radial artery and cephalic vein, for anastomosis; synthetic fistulas involve artificial vascular grafts, suitable for patients with poor vascular conditions.
The physiological mechanism involves arterial blood flow directly entering the vein, leading to vein dilation and wall thickening, forming a high-flow, high-pressure vascular structure. This change allows healthcare providers to easily puncture the fistula and ensures an hourly blood flow of 400-600 cc, meeting the requirements of hemodialysis.
Mainly suitable for patients with chronic kidney failure in stages IV to V, who are expected to need dialysis for more than 6 months. Suitable for patients with good vascular conditions and no severe peripheral vascular disease. Common indications include: adequate native vessels, high risk of infection from central venous catheters, or end-stage renal disease patients requiring long-term dialysis.
Physicians will calculate body surface area using Dubois formula and assess arterial blood flow and vein diameter via Doppler ultrasound. Patients with severe arterial stenosis or a history of thrombosis may need preoperative angioplasty or alternative access types.
The surgery is usually performed under local anesthesia, involving an incision to directly anastomose the artery and vein. The operation lasts about 1-2 hours, with 1-2 days of hospitalization for observation. Postoperative care includes daily checks for thrill or bruit in the fistula and avoiding heavy lifting on the operated arm.
During maturation, regular ultrasound follow-up is necessary to ensure blood flow exceeds 600 ml/min. When in use, adhere to the "upper arm preservation principle," avoiding blood sampling or infusion on the fistula side. After each dialysis puncture, confirm the fistula's normal function.
This treatment maintains patients' daily activity freedom without the need for daily device replacement. The success rate of autologous fistulas is approximately 70-90%, making it the current gold standard access option. Compared to catheters, fistulas reduce infection rates by over 60%, with less contact with non-biological materials.
Main complications include: thrombosis (incidence 10-20%), fistula failure, peripheral tissue edema, increased cardiac load. About 5-10% of patients may experience hyperperfusion syndrome, presenting as finger coldness and cyanosis. Surgical risks include nerve injury and arterial stenosis.
Long-term complications may include fistula infection (annual incidence about 5%), arterial aneurysm formation, which may require surgical repair. Diabetic patients may experience delayed fistula maturation due to metabolic abnormalities, requiring extended observation. Close monitoring of fistula blood flow dynamics is essential to prevent thrombosis and life-threatening events.
Contraindications include infection at the surgical site, severe arteriosclerosis, fistula-side heart failure, or systemic coagulation abnormalities. Preoperative assessment of Allen's test is necessary to ensure adequate hand blood flow compensation.
Postoperative care must strictly follow nursing guidelines: avoid water contact at the puncture site for 48 hours, daily palpation for thrill, and avoid blood pressure measurement on the operated arm. Severe contraindications include uncontrolled local infection, existing arterial aneurysm on the fistula side, or ongoing systemic anticoagulant therapy.
Use of anticoagulants (such as warfarin) increases intraoperative bleeding risk; INR should be adjusted below 1.5. Vascular damage related to radiotherapy may affect fistula function. Diabetic patients on hypoglycemic agents should be monitored for tissue repair postoperatively.
Interactions with other vascular access include avoiding placement of central venous catheters on the same side upper limb. Patients on antiplatelet therapy should have medication adjustments made in consultation with cardiologists.
Clinical studies show that the 1-year survival rate of successfully created autologous arteriovenous fistulas is about 85%, and 3-year survival is about 60%. Compared to catheters, fistulas reduce infection rates by 70% and decrease mortality by 40%. The US National Kidney Foundation recommends fistulas as the first choice for vascular access, with a puncture success rate of 75%.
Long-term follow-up indicates that fistula use can improve patient survival and quality of life. New endoscopic-assisted surgeries have reduced stenosis rates from 25% to 12%, demonstrating technological advancements that enhance treatment efficacy.
Alternatives include central venous catheters, synthetic grafts, or contralateral arm fistulas. Central catheters can be used immediately but have high infection risks; synthetic grafts are suitable for patients with poor vascular conditions but take longer to mature.
Temporary options such as tunneled catheters can be used as transitional devices before fistula maturation, with monthly infection rates up to 5%. Patients with poor vascular conditions in both arms may consider peritoneal dialysis or graft placement. Choice of options depends on overall health and vascular anatomy.
Patients need blood tests, cardiac function evaluation, and vascular ultrasound to confirm vascular suitability for surgery. Physicians will assess coagulation function, renal function, and potential comorbidities such as diabetes or hypertension control. Usually, anticoagulants are stopped 3 days before surgery, and dietary adjustments are made according to medical advice.
How to determine if the arteriovenous fistula is functioning normally after surgery?Patients can palpate or listen at the fistula site daily; a normal fistula should have a thrill or bruit. If the fistula feels hard, swollen, or lacks thrill, it may indicate thrombosis or infection, requiring immediate medical attention. Healthcare providers will regularly use ultrasound to monitor blood flow velocity and vessel diameter to ensure patency.
Can I shower or contact water normally after surgery?Wound should be kept dry within 24 hours post-surgery, using waterproof dressings during showering. If the wound heals well after one week, normal bathing is permitted, but soaking (such as bathing or hot water therapy) should be avoided. During fistula maturation (about 4-6 weeks), avoid blood pressure measurement, blood draws, or tight clothing on the fistula side.
What should I pay attention to regarding diet or exercise after arteriovenous fistula formation?It is recommended to consume a low-sodium, high-protein diet to maintain vascular health and avoid high-fat foods that may delay fistula maturation. Light exercises on the fistula side (such as grip exercises) are allowed, but heavy lifting or prolonged pressure should be avoided. Consult your doctor for guidance on vigorous or contact sports.
What are the treatment options if the fistula fails?If the fistula becomes stenotic or thrombosed, salvage procedures such as catheter angioplasty or thrombolytic therapy can be performed. Repeated failures may require removal of the original fistula and reconstruction at another site or switching to a central venous catheter for dialysis. Treatment choices depend on vascular conditions and overall health status.
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