Arteriovenous fistula creation is a surgical procedure used to establish a permanent vascular access, specifically designed for patients with chronic renal 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 cannulation as a dialysis access. This technique provides stable blood flow, ensuring smooth dialysis treatment.
The procedure is typically performed on the forearm, primarily involving an anastomosis between the patient's own artery and vein, which can be either end-to-end or end-to-side. Successfully established fistulas require 4 to 8 weeks to mature before use. This treatment effectively reduces the risk of infection associated with central venous catheters and improves dialysis efficiency.
Arteriovenous fistulas are mainly divided into "autologous arteriovenous fistula" and "synthetic graft fistula." Autologous fistulas use the patient's own blood vessels, such as the radial artery and cephalic vein, for anastomosis; synthetic graft fistulas use artificial vascular grafts, suitable for patients with poor vascular conditions.
The physiological mechanism involves arterial blood flow directly entering the vein, leading to dilation of the venous lumen and thickening of the vessel wall, forming a high-flow, high-pressure vascular structure. These changes make it easier for healthcare providers to cannulate and ensure an hourly blood flow of 400-600 ml, meeting the requirements of hemodialysis.
Mainly suitable for patients with stage 4 to 5 chronic renal failure 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 the 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 checks include daily palpation or auscultation for thrill, 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, follow the "upper arm preservation principle," avoiding blood sampling or infusion on the fistula side. After each dialysis puncture, confirm the fistula's functionality.
This treatment maintains patients' daily activity freedom without the need for daily equipment replacement. The success rate of autologous fistulas is approximately 70-90%, representing 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 (10-20%), fistula failure, peripheral tissue edema, increased cardiac load. About 5-10% of patients may experience overperfusion syndrome, presenting as cold fingers 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 life-threatening thrombosis.
Contraindications include infection at the surgical site, severe arteriosclerosis, fistula-side heart failure, or abnormal systemic coagulation function. Preoperative assessment of Allen's test is necessary to ensure adequate collateral circulation in the hand.
Postoperative care must strictly follow nursing guidelines: avoid water contact at the puncture site for 48 hours, daily check for thrill, and avoid blood pressure measurement on the operated arm. Severe contraindications include uncontrolled local tissue infection, existing arterial aneurysm on the fistula side, or ongoing systemic anticoagulant therapy.
The 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. When diabetic patients are on hypoglycemic agents, attention should be paid to tissue repair post-surgery.
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%, with a 3-year rate of approximately 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, with a puncture success rate of 75% as the primary target.
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 upper limb fistulas. Central catheters can be used immediately but carry high infection risks; synthetic grafts are suitable for patients with poor vascular conditions but require longer maturation times.
Temporary options like tunneled catheters can be used as transitional devices before fistula maturation, but the monthly infection rate can reach 5%. Patients with poor bilateral upper limb vasculature may consider peritoneal dialysis or graft placement. Choice of options depends on overall health and vascular anatomy.
Patients should undergo blood tests, cardiac function assessment, and vascular ultrasound to confirm vascular suitability for surgery. Doctors will evaluate coagulation function, renal function, and potential comorbidities such as diabetes or hypertension. Anticoagulants are usually stopped 3 days before surgery, and dietary adjustments should follow medical advice.
How to determine if the arteriovenous fistula is functioning normally postoperatively?Patients can palpate or auscultate the fistula daily; a normal fistula should have a thrill or a "buzzing" sound. If the fistula becomes hard, red, swollen, or lacks thrill, it may indicate thrombosis or infection, requiring immediate medical attention. Nursing staff will regularly use ultrasound to track blood flow velocity and vessel diameter to ensure patency.
Can I shower or contact water normally after surgery?The wound should be kept dry for 24 hours post-surgery, and waterproof dressings can be used during showering. If the wound heals well after one week, normal bathing is possible, but soaking (such as baths 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 arm.
What should I pay attention to in daily diet or exercise after 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 arm (such as grip strength exercises) are allowed, but heavy lifting or prolonged pressure should be avoided. Intense or contact sports should be adjusted according to medical advice.
What are the options if the fistula fails?If the fistula fails due to stenosis or thrombosis, 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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