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Arteriovenous fistula creation for hemodialysis and its complications

Arteriovenous fistula creation for hemodialysis and its complications
Literature review current through: Jan 2024.
This topic last updated: Aug 26, 2022.

INTRODUCTION — Two types of permanent vascular access are available for hemodialysis, the arteriovenous (AV) fistula and the AV graft. Of these, an AV fistula is preferred for long-term hemodialysis vascular access provided it is consistent with the patient's end-stage kidney disease (ESKD) Life-Plan and overall goals of care and patient circumstances are favorable for its creation. A mature, usable AV fistula is generally preferred to an AV graft for incident AV hemodialysis access due to fewer long-term vascular access events (eg, thrombosis, loss of primary patency, interventions) associated with unassisted AV fistula use [1]. AV fistula creation requires adequate arterial and venous anatomy to support its creation, and a sufficient time interval to allow the AV fistula to mature prior to its use. Unfortunately, failure of maturation remains a problem highlighting the importance of the preoperative evaluation [2]. (See "Risk factors for hemodialysis arteriovenous fistula failure" and "Primary failure of the hemodialysis arteriovenous fistula".)

The creation of native AV fistulas for hemodialysis and their complications are reviewed here. An overview of the different types of chronic hemodialysis access is presented separately. (See "Approach to the adult patient needing vascular access for chronic hemodialysis".)

GENERAL CHARACTERISTICS

Benefits and features — Arteriovenous (AV) fistulas are generally preferred over AV grafts. However, the temptation to create an AV fistula to satisfy the fistula-first initiative in patients with inadequate vessels should be resisted. Overly aggressive attempts to increase AV fistula prevalence in patients with suboptimal anatomy leads to reduced maturation rates and a longer duration of dialysis catheter use [3].

The benefits of AV fistulas over other forms of chronic access are discussed in detail elsewhere. (See "Approach to the adult patient needing vascular access for chronic hemodialysis".)

All types of AV fistulas possess similar characteristics. These include the following (see 'Types by anatomic location' below):

There is an increase in arterial and venous blood flow with time, which has the potential for causing cardiac overload (high-output cardiac failure) in susceptible patients. (See "Evaluation and management of heart failure caused by hemodialysis arteriovenous access".)

The diameter and flow within the associated artery increase with an abrupt initial increase at the time of fistula creation and a continued gradual increase thereafter [4,5]. This increase in flow may be compromised by calcified vessels.

Increased flow can also lead to distal extremity ischemia. Steal is more likely in patients undergoing brachial-based AV fistulas compared with radial artery-based fistulas [6,7]. (See 'Ischemia and other systemic problems' below.)

The AV fistula increases in diameter with time, which may cause cosmetic concern on the part of the patient. The fistula may also undergo aneurysmal degeneration over time. (See 'Aneurysm/pseudoaneurysm/megafistula' below.)

Requirements for AV fistula use — The goal is to create an accessible vascular structure with sufficient blood flow that can be cannulated repeatedly to permit adequate dialysis. Several characteristics must be present for an AV fistula to be usable. These include the following:

The AV fistula must be accessible with the patient in a comfortable sitting position.

In the forearm, the AV fistula should be on the volar surface.

In the upper arm, the AV fistula should be on the anterior or lateral surface.

The AV fistula must be able to be reliably cannulated repeatedly.

The AV fistula should be within 5 to 6 mm of the skin surface.

A relatively straight segment 8 to 10 cm long needs to be available for cannulation.

Blood flow must be adequate to support the dialysis prescription, generally at least 500 to 700 cc/min [8].

EVALUATION AND PLANNING — An adequate evaluation of the predialysis patient with chronic kidney disease enhances the opportunity to place a functioning arteriovenous (AV) fistula. A detailed medical history should be obtained to evaluate for risk factors. (See "Risk factors for hemodialysis arteriovenous fistula failure".)

Physical evaluation — Physical examination can often identify anatomy suitable for the creation of an AV fistula, but duplex ultrasound is generally used to evaluate the arterial and venous anatomy rather than relying on physical examination alone [9]. Combined with clinical judgment and physical exam findings, this is the optimal means of access planning. Patient evaluation and vascular mapping prior to placement of hemodialysis AV access is discussed in detail separately. Vein diameter (measured by ultrasound) of at least 2.5 mm under tourniquet in a warm room is generally considered the minimum diameter to reliably create a fistula [10]. This issue is discussed in more detail elsewhere. (See "Patient evaluation prior to placement of hemodialysis arteriovenous access".)

When planning the creation of an AV fistula, attention should be directed to the nondominant arm first. While the patient is on dialysis, having the dominant hand free allows the patient to engage in desired activities more easily. However, if the nondominant arm is not suitable for AV fistula creation, the dominant arm should be evaluated. In most patients, only after determining that conditions are not suitable for an AV fistula should an AV graft be considered.

Timing of AV fistula creation — It is important to realize that it takes time to arrive at a successful AV fistula. There are a number of events that must take place, including referral to surgery, surgical evaluation, possible medical workup to ensure safe surgical process, scheduling for surgery, a period of maturation, and the possibility of a need for a salvage procedure to achieve usability, which may be followed by another waiting period before it is finally declared suitable for use. Each of these events takes time. This sequence has been referred to as the "fistula hurdles." During this sequence, the patient falls into one of two categories: (1) continuing dialysis with a catheter, or (2) the risk of having to start dialysis with a catheter. Both of these are undesirable.

The minimum time for AV fistula maturation is one month [11], but a lead time of 6 to 12 months is recommended since intervention may be required to facilitate maturation of AV fistulas, particularly for patients with small vessels below the accepted thresholds for access creation [12]. (See "Early evaluation of the newly created hemodialysis arteriovenous fistula" and "Overview of hemodialysis arteriovenous fistula maintenance and thrombosis prevention", section on 'Inspection prior to initial cannulation'.)

In one study, AV fistulas created at least four months prior to starting hemodialysis were associated with a lower risk of sepsis and mortality [13]. Much of the benefit was explained by the avoidance of central venous catheters.

According to one report [14], within a cohort of 78 patients who started dialysis with a tunneled catheter, it was observed that the likelihood of using a permanent access was 53 percent by six months and only 80 percent by one year. In patients with both a catheter and an immature access, 50 percent were using their permanent access at three months and 80 percent at six months. Of patients using a catheter with access surgery pending, 45 percent had access surgery performed within three months and only 70 percent at six months.

It is well documented that patients who see a nephrologist prior to the need for dialysis have a better chance of starting dialysis with an AV fistula as a permanent access [15,16]. However, even when patients are referred to a nephrologist prior to their need, they frequently incur a delay in having a permanent AV access placed and require catheter-based dialysis.

It was shown that patients referred within one month prior to initiating hemodialysis therapy used a dialysis catheter for a median of 202 days [17]. For patients referred within one to four months prior, it was 64 days; within 4 to 12 months, the time was 67 days; and with referral greater than 12 months before initiating hemodialysis therapy, catheter use was still for a median of 19 days.

In a study of 157 patients initiating dialysis therapy, 73.2 percent had predialysis care by a nephrologist [18]. Of these, only 46.5 percent had predialysis vascular access surgery, and only 35 percent initiated their first dialysis session with a permanent access.

Access planning is a complex issue with a number of problems that must be addressed [19]. It is very clear that there is a need for an improved algorithm relating declining renal function and timing of the referral for access placement. Creating the AV fistula before it is required for dialysis allows adequate maturation to take place prior to use and may avoid the need for a dialysis catheter. However, creating a fistula very early is not without the potential for complications, and a significant percentage of patients who undergo preemptive access do not go on to require dialysis [20-22]. The patient should be sent to the surgeon before the time of anticipated need for access, generally when the estimated glomerular filtration rate (eGFR) is 5 to 15, which is intended to balance the time needed to mature a fistula and the possibility of fistula malfunction prior to any use.

Fistula creation at least four months before starting chronic hemodialysis has been shown to be associated with the lowest risk of sepsis and death from the use of hemodialysis catheters. In this retrospective study [13]:

AV fistulas or AV grafts created at least four months before starting hemodialysis were defined as Early creations (n = 1240).

Accesses created between four months and one month before starting hemodialysis were defined as Just Prior creations (n = 997).

Accesses created within one month of starting dialysis or after were defined as Late creations (n = 3687).

Hemodialysis catheter use was defined as insertion, removal, or manipulation of a catheter before the occurrence of sepsis.

Eighty percent of accesses were AV fistulas. Early access creation was associated with a decreased risk of sepsis compared with late access creation, with catheter use increasing the risk of sepsis by 1.41. Early access creation was also associated with lower mortality. Catheter use and sepsis independently increased mortality.

Open surgical versus percutaneous approach — Surgical creation of an AV fistula is the standard technique and is the focus of the discussion below.

However, evolving therapies have allowed the creation of arteriovenous connections using endovascular techniques [6,23-27]. Using this approach, specially designed catheters are used to join the walls of the antecubital vessels to create the fistula. Two technologies approved for use in the United States are available for percutaneous (pAVF) creation; these techniques are only just beginning to be used on a larger scale. While initial clinical success rates in pivotal trials has been high, studies with more patients, longer follow-up, and controlled comparisons with surgical access creation are needed. Variables for access evaluation and planning, as well as follow-up, maintenance, and care of percutaneous AV fistulas, are being actively investigated. (See "Percutaneous hemodialysis arteriovenous fistula".)

Types by anatomic location — The type of AV fistula should be referred to by the specific artery and vein that are involved [28]. The venous anatomy of the upper extremity is illustrated in the figures (figure 1A-B).

Although a variety of different anatomic types of AV fistula can be created, most AV fistulas fall within these basic types:

Radial-cephalic, which is the radial artery and the cephalic vein at the wrist

Forearm basilic, which is the radial or ulnar artery and the basilic vein at the wrist

Brachial-cephalic, which is the brachial artery and the cephalic vein in the proximal forearm

Brachial-basilic, which is the brachial artery and the basilic vein in the upper arm

Lower extremity, which is the superficial femoral artery and the saphenous or femoral/popliteal vein in the thigh

The radial-cephalic AV fistula has a lower blood flow rate than the more proximal AV fistulas. Its use as the first access preserves the more proximal arm vessels for later access attempts. It is generally a comfortable means of dialysis, requires less frequent superficialization, and may dilate the more proximal veins to enable easier fistula creation in the future.

The forearm basilic AV fistula can be created using either the radial artery or the ulnar artery as inflow [29]. The distal segment of the basilic vein may need to be mobilized and transposed to be anastomosed to the radial or ulnar artery. The primary and secondary patency rates at one year for the forearm-basilic AV fistula are approximately 50 and 70 percent, respectively [29-32]. Maturation rates are reported to be as low as 60 percent [29]. However, the complication rates of vascular access-related hand ischemia and infection are very low.

The brachial-cephalic fistula is created by anastomosing the upper arm cephalic vein to the brachial artery in the antecubital fossa or just above the elbow. Because of the lateral and relatively superficial location of the cephalic vein, the brachial-cephalic fistula is easy to cannulate. It also provides a long length of straight vein from which to select cannulation sites. In patients with obesity or those in whom the cephalic vein is deeper than 5 to 6 mm from the skin, the brachial-cephalic fistula may require superficialization to make it possible to be cannulated. This more proximal access has the potential for a higher blood flow than the radial-cephalic fistula and also has a higher incidence of vascular steal syndrome.

The brachial-basilic fistula (basilic vein transposition) requires a more extensive operation to create. The basilic vein lies on the inner surface of the forearm in the median bicipital sulcus. It continues proximally to the middle third of the sulcus, at which point it pierces the brachial fascia to run in a deeper plane. Thus, the vein must be elevated and transposed to make it usable as a hemodialysis access. The basilic vein is dissected free from its bed by ligating and dividing all tributaries to the point where it joins the brachial vein to form the axillary vein in the upper arm. The basilic vein is then transposed to a more superficial location to move it from its medial position to a more lateral location that is accessible for dialysis. The brachial-basilic fistula can be created as a one-stage procedure or in two stages. In the one-stage procedure, the brachial-basilic anastomosis and the basilic vein superficialization are performed in the same operation. In the two-stage procedure, the brachial-basilic anastomosis is created in the first operation and the fistula is allowed to mature for four to six weeks. A second operation is then performed to superficialize the brachial-basilic fistula. In the literature, there appears to be no difference in maturation and patency rates among the one- and two-stage approach. However, there is some indication that the two-stage approach is more successful in patients with smaller basilic veins [33-35]. The brachial-basilic AV fistula is associated with more morbidity related to its creation. However, because the basilic vein is more deeply positioned and therefore less accessible for venipuncture under normal circumstances, it tends to be better preserved and less involved with postphlebitic changes compared with the cephalic vein.

The basilic vein is shorter than the cephalic vein, especially if its confluence with the brachial vein is low in the upper arm. Under this circumstance, the brachial vein can also be mobilized and transposed. Shorter cannulation lengths are common with obese arms, so care must be taken to either mobilize a longer piece of vein (into the forearm) or to resect fat and muscle from the upper arm to ensure an adequate length of the cannulation segment.

Steal syndrome tends to be more common for brachial artery-based fistulas [36]. This may in part be related to the larger size of the veins or because the brachial artery at the antecubital fossa is the only supply for the hand, whereas the ulnar artery is intact with a radial artery-based access [37]. In addition, the basilic vein access tends to be used primarily in patients who have had multiple prior failed access procedures. These patients, as a group, tend to have a higher incidence of arteriosclerotic arterial disease, making them more susceptible to steal. (See 'Ischemia and other systemic problems' below and "Hemodialysis access-induced distal ischemia".)

It is imperative to screen for significant PAD when evaluating a patient for a lower extremity vascular access. Placement of a thigh vascular access in patients with significant PAD can result in ischemic steal, leading to limb-threatening ischemia, gangrene, and amputation. Patients with severe PAD should not undergo thigh vascular access without concomitant revascularization. An AV fistula in the thigh can be constructed using the transposed femoral and popliteal vein. The femoral/popliteal vein is mobilized from the knee joint to the confluence of the deep femoral and femoral veins. It is then transposed through a superficial tunnel, tapered, and anastomosed to the superficial femoral artery just proximal to the adductor hiatus. Tapering of the vein reduces the risk of ischemic steal. The femoral vein transposition AV fistula is a technically demanding operation that involves a complex dissection of the femoral vein, so it is usually reserved for good risk patients [38-41]. Thigh AV fistula performed using the saphenous vein is less technically demanding; however, results are not satisfactory, due to the lack of dilation of the great saphenous vein over time [42]. To address this issue, some have proposed constructing a semipanel great saphenous vein graft, which effectively increases the diameter [43].

PROCEDURE — Arteriovenous (AV) fistulas can generally be created quickly with minimal patient morbidity.

Anesthesia — Options for anesthesia at the time of AV fistula creation include general anesthesia, regional anesthesia, or local anesthesia. Avoiding general anesthesia is desirable in this population, and, under most circumstances, AV fistula creation can be accomplished using regional or local anesthesia with or without intravenous sedation. Based upon the results of one trial, we suggest brachial plexus block rather than local anesthesia alone for the creation of AV fistulas. Regional anesthesia causes arterial and venous dilation and improves fistula patency [44-46]. However, potential improvements in fistula patency need to be weighed against the risks associated with brachial plexus block, which may be reduced using ultrasound guidance. (See "Upper extremity nerve blocks: Techniques", section on 'Brachial plexus blocks'.)

There is some evidence that brachial plexus blocks may be beneficial by causing regional sympathetic blockade, which results in arterial and venous vasodilation [47-49]. The venodilation caused by the regional block appears to improve the successful creation and use of AV fistulas [45,49]. However, whether assisted primary patency or secondary patency rates (figure 2 and table 1) differ is unknown.

In a randomized trial of infraclavicular brachial plexus block versus local infiltration anesthesia, patients in the block group had significantly higher rates of AV fistula blood flow eight weeks postoperatively compared with patients in the local anesthesia group [50]. However, there was no difference in rates of early failure between the two groups, which may be due to the small sample size of 30 patients in each group.

A larger trial randomly assigned 126 adults receiving primarily radiocephalic or brachiocephalic fistulas to local anesthesia (0.5% L-bupivacaine and 1% lidocaine injected subcutaneously) or brachial plexus block anaesthesia (0.5% L-bupivacaine and 1.5% lidocaine with epinephrine) [45]. For the entire group, primary patency at three months was significantly higher in the brachial plexus block group compared with local anaesthesia (53 of 63 patients [84 percent] versus 39 of 63 [62 percent]; odds ratio [OR] 3.3, 95% CI 1.4-7.6). Assisted primary patency and secondary patency rates were not reported, but initial patency has been correlated with improved outcome. No complications related to brachial plexus block occurred in this study.

A meta-analysis that included six randomized trials and one observational study reported that AV fistula primary patency was increased for regional anesthesia compared with local anesthesia (relative risk [RR] 1.22, 95% CI 1.08, 1.37) [46].

Antimicrobial prophylaxis — Antibiotic prophylaxis is indicated at the time of the surgical creation or revision of an AV hemodialysis access (table 2 and table 3); antibiotic administration with routine use of the access during hemodialysis has been unsuccessful in preventing fistula infection and may be dangerous. The use of nasal mupirocin to eradicate nasal carriage of Staphylococcus aureus can reduce the incidence of S. aureus bacteremia in hemodialysis patients. However, this approach is complicated by the development of mupirocin resistance with chronic use [51]. Thus, nasal mupirocin is best reserved for patients with repeated infection and nasal S. aureus carriage and in the setting of epidemic infections in the dialysis unit.

Fistula creation — Although there are AV fistulas that are more commonly created, a fistula can be fashioned anywhere a vein of sufficient diameter is located or can be moved into position near and anastomosed to an artery of adequate size. The anastomosis for any fistula is typically created using a 7-0 to 5-0 monofilament suture in a running fashion. The smaller the vessels, the finer the choice of suture.

Fistula types are classified as simple direct, vein transposition, or vein translocation based upon how they are created. Each is discussed in more detail below.

Simple direct fistula — A simple direct fistula is a straightforward fistula to create since the vein and the artery are used in their normal positions. The distal end of the vein is dissected free and sutured to an adjacent artery. Examples are:

Radial artery-to-cephalic vein (wrist)

Radial artery-to–basilic vein (forearm, in some cases, generally requires transposition)

Radial artery-to-median antecubital vein (forearm)

Radial artery–to-median antebrachial (forearm)

Brachial artery-to-cephalic vein (upper arm)

Femoral artery-to–saphenous vein (lower extremity)

Femoral artery to femoral vein (lower extremity)

One of the most common causes of primary radiocephalic AV fistula failure is a juxta-anastomotic stenosis that occurs where the cephalic vein turns toward the radial artery. Particular attention must be paid to this area to minimize sharp angulations. One technique to address this is the piggyback straight line onlay technique (pSLOT), which decreases the incidence of primary failure due to juxta-anastomotic stenosis [52]. With the pSLOT technique, the posterior aspect (underside) of the cephalic vein is anastomosed to the anterior aspect of the radial artery in a side-to-side fashion. Care is taken to dissect the outflow vein further into the subcutaneous tissue to ensure that the vein has a straighter lie without an abrupt turn. An alternative option is the radial artery deviation and reimplantation (RADAR) technique, which is intended to minimize manipulation of the vein and reduce the risk of juxta-anastomotic stenosis in the swing segment. In RADAR, the radial artery is ligated at the wrist [53]. The distal end of the artery, proximal to the ligation, is turned toward the cephalic vein. An anastomosis is then created from the end of the artery to the side of the vein.

Brachiocephalic AV fistulas are typically performed through a transverse incision in the antecubital fossa, avoiding the antecubital crease itself [54]. Use of a 6 to 7 mm arteriotomy in the brachial artery and liberal use of a venous footplate has been associated with increased primary functional patency at 12 months [55]. A footplate is created by transecting the cephalic vein near a branch point (figure 3). The branch vein is also transected 2 to 3 mm from the cephalic vein. The bridge between the cephalic vein and the branch is divided, creating a footplate, which is then used to create the end-to-side anastomosis. Similar to the radiocephalic fistula, the juxta-anastomotic area is at risk for stenosis if there is a sharp turn in the vein [56]. Care should be taken to perform extended dissection in this area to ensure a straight lie of the cephalic vein.

Vein transposition fistula — With a vein transposition fistula, the vein is moved or transposed to a position that is better suited for the construction or cannulation of a fistula. Although the downstream or proximal end of the vein is left intact, the tributaries to the distal portion are divided and ligated to allow the vein to be moved to a position that will facilitate ease of cannulation when the fistula is used for hemodialysis. This requires the creation of a tunnel or pocket to serve as a bed for the positioned vein. This is occasionally performed in a two-stage operation. Examples are:

Radial-cephalic transposition (wrist, patients with obesity)

Radial-basilic transposition (forearm, in most patients)

Brachial-basilic transposition (upper arm)

Brachio-brachial transposition

Brachial-cephalic transposition (upper arm, patients with obesity)

Femoral-saphenous transposition (thigh, patients with obesity)

Femoral artery to femoral vein (thigh)

Vein translocation fistula — With a vein translocation fistula, a vein is removed from its normal anatomic location to another location and thus requires the creation of a venovenous anastomosis and venoarterial anastomosis. The construction of a vein translocation fistula is similar to the placement of an AV graft. The only difference is that the patient's vein is used instead of prosthetic material. The procedure similarly requires the creation of a subcutaneous tunnel to position the vein into its new location.

The most common veins that are translocated include the great saphenous vein and the femoral vein [57-59]. The great saphenous vein can generally be easily harvested; however, because of the magnitude of the operation and potentially serious complications associated with the harvest of the femoral vein, it is rarely used to create an AV fistula.

FOLLOW-UP — Following its creation, the newly created AV fistula should be examined by the surgeon who created the access within two weeks to assess for surgical complications [1].

Once a fistula is created, it must develop to the point that it is usable. This principally means that the arteriovenous (AV) fistula must provide adequate blood flow to support the hemodialysis prescription and must support repeated cannulations. Early imaging and secondary procedures should be electively performed to rescue AV fistulas with primary failure that fail to adequately mature. (See "Early evaluation of the newly created hemodialysis arteriovenous fistula".)

Measures to prevent the failure of hemodialysis arteriovenous (AV) fistulas are discussed elsewhere. (See "Overview of hemodialysis arteriovenous fistula maintenance and thrombosis prevention" and "Clinical monitoring and surveillance of the mature hemodialysis arteriovenous fistula".)

COMPLICATIONS OF AV FISTULA PLACEMENT

Local problems

Bleeding — Bleeding complications with arteriovenous (AV) fistula creation are uncommon. Hemodialysis-dependent patients may have some generalized ooze during the operation due to platelet dysfunction, which can be treated with administration of desmopressin. Surgical bleeding should be managed with suture repair. Other minor bleeding can be treated with hemostatic agents such as cellulose products or thrombin. (See "Overview of topical hemostatic agents and tissue adhesives" and "Fibrin sealants".)

Venous hypertension — Extremity swelling is most commonly due to central vein stenosis but can also be due to venous valvular incompetence, which results in chronic elevation of the venous pressure in the extremity. The resulting venous hypertension can lead to skin discoloration, access dysfunction, and, potentially, ischemic changes of the skin. Although mild-to-moderate extremity swelling is common initially following access surgery, it usually subsides. (See "Central vein obstruction associated with upper extremity hemodialysis access".)

Prior to the creation of an AV fistula, venography may be performed in patients who are suspected of having central venous stenosis, as evidenced by dilated chest wall veins. A history of chronic ipsilateral tunneled catheter use, previous port placement, pacemaker or defibrillator placement, or history of heart transplant should prompt preoperative imaging. (See "Patient evaluation prior to placement of hemodialysis arteriovenous access".)

Aneurysm/pseudoaneurysm/megafistula — Aneurysms/pseudoaneurysms of AV hemodialysis access are at risk for complications, including rupture, infection, bleeding, erosion of the overlying skin, and difficulty with cannulation.

True aneurysms are abnormally dilated (>1.5 times the normal diameter) focal regions of a blood vessel that contain all the layers of the vessel wall. The etiology of true aneurysms in AV fistulas is unclear. Proposed etiologies include increased venous pressure due to a central venous stenosis, repeated punctures at the same site, and immunosuppression [60,61].

A pseudoaneurysm represents a focal disruption of the vessel wall with a collection of blood outside the vessel wall that is contained by fibrous tissue. Pseudoaneurysms usually result from repeated cannulation in the same area of the access [62,63]. Cannulation through a pseudoaneurysm should be avoided. Pseudoaneurysms can be prevented by rotating the sites of needle insertion. (See "Overview of hemodialysis arteriovenous fistula maintenance and thrombosis prevention".)

Aneurysms/pseudoaneurysms are at risk for complications, including rupture, infection, and erosion of the overlying skin. Changes that require urgent evaluation to prevent rupture include the presence of a nonhealing eschar, spontaneous bleeding from access sites, and rapid expansion in size of the aneurysm [64,65]. The 2019 Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines and the 2006 Canadian Society of Nephrology hemodialysis guidelines suggest that AV fistulas should be revised when an aneurysm develops if [1,66]:

The skin overlying the fistula is compromised

There is a risk of fistula rupture

Available puncture sites are limited

Infection — The vascular access is the source of the majority of bacteremia in hemodialysis patients. S. aureus and, less commonly, Staphylococcus epidermidis are the predominant pathogens [67-71]. Bacteremia frequently occurs during cannulation without actual AV access infection. The incidence of infection associated with AV fistulas is low. In a meta-analysis that included 76 studies with an outcome of infection, the rate of AV fistula site infection over the study period was 3.7 percent, with a rate per 100 access days of 2.0 percent [72].

Risk factors for AV fistula infection include pseudoaneurysms, hematomas, severe pruritus and scratching over needle sites, the use of hemodialysis fistulas as a route of access for injection drug abuse, creation of buttonhole versus traditional "rope and ladder" cannulation, and manipulation of the access during secondary surgical procedures [73,74].

Infection occurring in AV fistulas can usually be treated with intravenous antibiotics and, if necessary, surgical drainage. Since AV fistulas are rarely the primary source of the infection in the absence of a collection of pus, bacteremia is assumed to be a consequence of endocarditis. Thus, the 2019 Kidney Dialysis Outcomes Quality Initiative (KDOQI) guidelines recommend six weeks of antibiotic therapy for access-mediated bacteremia in a patient with an AV fistula [1]. With septic emboli, surgical excision of the fistula should be performed.

Neuropathy — Median nerve dysfunction in long-term dialysis patients is most often due to local amyloid deposition, leading to carpal tunnel syndrome. (See "Dialysis-related amyloidosis".)

The vascular access also may contribute to this neuropathy in some cases via compression of the median nerve (due to the extravasation of blood or fluid) or via ischemic injury from a vascular steal effect (ischemic monomelic neuropathy) [75-78].

Primary failure and failure of mature AV fistula — AV fistula dysfunction and failure related to failure to mature and stenotic vascular lesions are the most common complications of AV fistulas. These issues are discussed elsewhere. (See "Primary failure of the hemodialysis arteriovenous fistula" and "Failure of the mature hemodialysis arteriovenous fistula".)

Ischemia and other systemic problems

Dialysis access steal syndrome and ischemic monomelic neuropathy — Ischemic complications of hemodialysis AV access occur for a variety of reasons that almost always include decreased blood flow to the distal extremity resulting from increased blood flow through the AV access. Dialysis access steal syndrome (DASS) presents with typical clinical features of upper extremity ischemia (hand pain, coolness, diminished sensory/motor function) and can occur in high- or low-volume-flow AV accesses. Ischemic monomelic neuropathy (IMN) is a very rare variant of DASS that presents with severe hand pain related to predominantly nerve ischemia. Differentiating IMN from DASS is important to implement appropriate treatment. We agree with guidelines that recommend immediate AV access closure when IMN is diagnosed [1]. Treatment options for DASS include AV access ligation for severe ischemia, banding procedures to reduce flow in the high-flow AV access, and procedures to improve distal blood flow in the low- or normal-flow AV access (algorithm 1). (See "Hemodialysis access-induced distal ischemia".)

Coronary steal — Symptomatic steal from an internal mammary artery coronary artery bypass from an ipsilateral upper extremity dialysis fistula has been reported to cause myocardial ischemia [79,80]. When planning vascular access placement in a patient with an internal mammary bypass, it is best to use the upper extremity contralateral to the internal mammary graft [80-82]. Likewise, when contemplating use of the left internal mammary for coronary bypass in a dialysis patient with a left upper-extremity shunt, it may be useful to angiographically document the absence of reversal of flow in the internal mammary artery during diastole before using that artery as a coronary bypass [83].

Heart failure — Vascular access-related cardiac decompensation is a rare complication, even in patients with underlying cardiac dysfunction. Patients with an AV fistula do not have higher rates of heart failure than patients using AV grafts or indwelling catheters for dialysis but may have worsening of preexisting left ventricular hypertrophy after creation of the fistula. These issues are discussed separately. (See "Evaluation and management of heart failure caused by hemodialysis arteriovenous access".)

Pulmonary hypertension — Pulmonary disease is an important comorbidity in those with chronic kidney disease (CKD) and is associated with an increased risk of cardiovascular events and overall mortality. A high incidence of pulmonary hypertension (PH) occurs in patients with CKD, but the highest level occurs in the dialysis patient, particularly those dialyzing with an arteriovenous access. (See "Pulmonary hypertension in patients with end-stage kidney disease".)

OTHER COMPLICATIONS

Other swelling – Swelling of the shoulder, chest wall, or breast can occur, more typically in those with central vein stenosis/thrombosis, but it can also occur in the absence of occlusion [84]. It is important to differentiate late development of unilateral breast swelling related to hemodialysis arteriovenous (AV) access from other potential etiologies (eg, inflammatory breast cancer, nephrogenic systemic fibrosis).

Malignancy – Rarely, malignancy (eg, angiosarcoma, others) has been reported at the site of hemodialysis AV access [85-88]. Angiosarcoma appears to be most commonly seen in post-transplant patients (86 percent in one review [85]) who may or may not be immunosuppressed at the time of the diagnosis. It has been reported at sites of both functioning and nonfunctioning hemodialysis AV access. Symptoms include development of pain alone or pain associated with a mass/swelling that may have overlying ulceration/bleeding [85].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Dialysis" and "Society guideline links: Hemodialysis vascular access" and "Society guideline links: Acute extremity ischemia".)

SUMMARY AND RECOMMENDATIONS

All arteriovenous (AV) fistulas possess similar characteristics. These generally include an increase in size and blood flow with time and lower rates of venous stenosis and infection compared with AV grafts. To be usable, several characteristics must be present for an AV fistula. These include adequate blood flow, reliable repeated cannulation, accessibility in a sitting position, and adequate maturation. (See 'Requirements for AV fistula use' above.)

An adequate evaluation of the predialysis patient with chronic kidney disease enhances the opportunity to provide a functioning AV fistula. This includes a history, physical examination, ultrasound vein mapping, and arterial and venous evaluation. (See 'Physical evaluation' above and "Patient evaluation prior to placement of hemodialysis arteriovenous access".)

AV fistulas can generally be created quickly with minimal patient morbidity. Based upon how they are created, AV fistulas can be classified into three different categories: simple direct fistulas, vein transposition fistulas, and vein translocation fistulas. AV fistulas should be referred to using anatomical designations that include the donor artery and outflow in their description, such as radial-cephalic, which is the radial artery and the cephalic vein; brachial-cephalic, which is the brachial artery and the cephalic vein; and brachial-basilic, which is the brachial artery and basilic vein. (See 'Types by anatomic location' above.)

Among the possible AV fistulas, we generally start distally in the extremity, initially creating a radial-cephalic fistula, provided it is anatomically feasible. If a radial-cephalic fistula is not possible, we move more proximally to create a brachial-cephalic fistula. If a radial-cephalic or brachial-cephalic fistula is not possible, we create a brachial-basilic fistula rather than another type of AV fistula. (See 'Types by anatomic location' above.)

Regional anesthesia during the creation of hemodialysis AV fistulas causes arterial and venous dilation and may improve early fistula patency. These improvements in fistula patency and the decreased risk compared to general anesthesia generally outweigh the low risks associated with brachial plexus block, especially when done under ultrasound guidance. (See 'Anesthesia' above and "Upper extremity nerve blocks: Techniques", section on 'Brachial plexus blocks'.)

ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledge Gerald A Beathard, MD, PhD, who contributed to an earlier version of this topic review.

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References

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