Haemodialysis upper limb arteriovenous fistula

An acquired arm arteriovenous fistula (AVF) creation is a procedure performed for haemodialysis access in those with end stage renal failure. It connects and artery to a vein in the vein. This can either be a native connection or a connection using a PTFE (polytetrafluoroethylene) graft.

There are several types depending on the type of connection:

• forearm arteriovenous fistula (AVF)
  • radial artery to cephalic vein
  • radial artery to basilic vein or other suitable forearm vein (transposition)
• upper arm arteriovenous fistula 
  • brachial artery to cephalic vein
  • brachial artery to basilic or other suitable upper arm vein (transposition)
• dual outflow fistula 
  • brachial artery to cephalic and basilic vein
  • radial artery to cephalic and basilic vein
• forearm graft
  • brachial artery and median antecubital vein, a “loop” graft
• upper arm graft
  • brachial artery and high brachial vein or basilic vein, a “straight” graft

Radiographic assessment

Preoperative assessment

Ultrasound

Upper arm mapping

A tourniquet is placed near the axilla, and the cephalic, basilic and brachial veins from the antecubital area to the cranial aspect of the upper arm are examined. Veins of acceptable diameter are followed into the subclavian vein to assess for stenosis or occlusion by using direct non-compressive assessment and compression techniques.

Assessment of draining veins

All draining veins are assessed for stenosis/thrombosis throughout their course with visual inspection and compression.

• indirect central venous assessment
  • subclavian and jugular venous Doppler waveforms are analysed for indirect evidence of central venous abnormality.
  • indirect evidence of stenosis or occlusion in the nonvisualised brachiocephalic vein and/or superior vena cava include
    • diminished respiratory phasicity
    • diminished transmitted cardiac pulsatility in the subclavian and jugular veins

Venography

Content pending.

Postoperative assessment

Ultrasound

Ultrasound is mainly used to assess for patency and complication.

Venography

Content pending. 

Complications

• non-maturity
  • outflow stenosis: some publications suggest a flow velocity of 400 cm/s or greater is indicative of a stenosis ⁵
• thrombosis/occlusion
• haematoma
• pseudoaneurysm formation
• aneurysm formation: aneurysms associated with arteriovenous fistulae (may occur in around 5% of cases ¹²)
• perigraft fluid

See also

• Haemodialysis vascular access
• Endovascular arteriovenous fistula creation