AV Fistula: A Long-Term Solution for Dialysis Access

By: dr. Ihza Fachriza, Sp.B, Subsp.BVE(K)

AV Fistula for Hemodialysis: A Lifeline That Needs to be Protected 

For kidney failure patients undergoing regular hemodialysis, access to strong and durable blood vessels is truly a lifeline. Dialysis machines require a substantial and stable blood flow several times a week.

An arteriovenous (AV) fistula is one of the best forms of vascular access for hemodialysis. This fistula is created by a vascular surgeon by directly connecting an artery and vein in the arm, creating a larger and stronger blood vessel capable of repeated punctures.

Numerous international guidelines still consider AV fistulas the primary access option due to their excellent survival rates and fewer long-term complications compared to grafts or catheters.

Why Do Hemodialysis Patients Need Special Vascular Access? 

In hemodialysis, the patient's blood must:

• It exits the body at a fairly high flow rate (usually 300–500 mL/minute),
• passes through a filter in the machine,
• and then returns to the body.

for 3–4 hours per session, several times a week.

The normal blood vessels in the hands are not designed for:

• being repeatedly stabbed with a large needle.
• subjected to such high blood flow for a prolonged period.

If forced, blood vessels can quickly become damaged, leak, or become blocked. Therefore, hemodialysis patients require specialized vascular access that:

• capable of providing high blood flow,
• strong enough for repeated needle insertions,
• and expected to be long-lasting.

AV fistula meets these criteria, so it is also called the “gold standard” of hemodialysis access.

What is an AV Fistula? 

Fistula AV (arteri-vena) adalah sambungan bedah antara satu arteri dan satu vena, biasanya di lengan bawah atau lengan atas. 
Dengan membuat hubungan langsung ini: 

• As arterial blood pressure and flow increase, the veins move into the veins.
• The veins become larger, thicker, and stronger (this process is called maturation/"vein arterialization"),
• so that once mature, the veins can be used for routine hemodialysis needle insertion.

The advantages of an AV fistula compared to a central venous catheter include:

• No foreign objects because it uses your own body parts.
• Lower risk of infection.
• Lower risk of blockage (thrombosis).
• Longer lifespan in general.

The Process of Creating an AV Fistula by a Vascular Surgeon 

Before surgery, the vascular surgeon will:

1. Assess the patient's general condition

• Medical history, medications, and readiness for minor surgery.

2. Pemeriksaan pembuluh darah (vascular mapping) 

• Physical examination of the arm: palpating pulses and assessing vein size.
• A Doppler ultrasound is often used to measure the diameter and quality of arteries and veins, allowing for the optimal fistula location (e.g., wrist/radiocephalic or upper arm/brachiocephalic).

During Operation:

• Performed in an operating room, usually under local or regional anesthesia.
• The doctor makes a small incision in the arm,
• connecting the artery to the vein using a special suture technique.
• After completion, blood flow to the vein will increase; if successful, a gentle thrill will be felt in the fistula area.

Length of stay can vary depending on the patient's condition and hospital policy, but many patients can go home within 1 day if stable.

When is the Best Time to Make a Fistula?

Ideally, an AV fistula is created before the patient actually requires regular hemodialysis, so that there is time for the fistula to mature and be ready for use.

In general: 

• A fistula takes approximately 6–12 weeks to mature, although in some patients it can take longer or shorter.
• Therefore, patients with chronic kidney disease are usually advised to consult a nephrologist and vascular surgeon early for access planning.

Modern vascular guidelines (KDOQI) emphasize the importance of planning access according to the patient's “life-plan” and avoiding starting hemodialysis with a catheter whenever possible.

How to Care for and Keep Fistulas Good

Once the fistula is created, the role of the patient and family is very important to keep the fistula healthy.

Some principles of care: 

1. Protect the fistula arm

• Do not measure blood pressure in the arm with the fistula.
• Do not insert an IV, draw blood, or administer an injection in that arm.
• Avoid carrying heavy objects or putting pressure on the arm on the side of the fistula (e.g., lying on it while sleeping) during the initial phase. 

2.Check “thrill” every day

• Place your finger over the fistula and feel for a gentle vibration, like a "small engine" under your skin.
• If the vibration weakens or disappears, immediately notify the dialysis team or go to the hospital.

3. Keep the skin around the fistula clean

• Follow the nurse's instructions on how to change the post-operative dressing.
• After the surgical wound has healed, keep your arm clean with soap and water and dry it gently.

4.Avoid trauma

• Avoid excessive scratching, hitting, or applying pressure to the fistula area.
• Be careful when wearing watches, bracelets, or tight clothing around the area.

The hemodialysis team and nurses will provide more detailed education according to each patient's condition.

Complications to Watch Out For

In general, AV fistula is a safe and effective access, but it can still experience complications, such as:

• Blind fistula (thrombosis/stenosis)
  Sudden loss of sensation or decreased blood flow during dialysis.
• Infection
  Redness, pain, swelling, or pus around the fistula.
• Aneurysm/excessive dilation of the fistula vein
  A lump that grows larger; the overlying skin becomes thinner.
• Steal syndrome
  The hand below the fistula may feel cold, numb, weak, or painful because too much blood is being drawn into the fistula.
• Excessive swelling or venous hypertension

If any of the above signs appear, patients should immediately consult a hemodialysis and vascular surgery team. Early examination and intervention can help preserve the fistula and ensure its continued use.

QnA about AV Fistula 

Q: When should an AV fistula be created?
A: Ideally, an AV fistula is created before routine hemodialysis begins, when kidney function is close to requiring dialysis but the patient is not yet on frequent dialysis. The goal is to give the fistula 6–12 weeks to mature so that by the time hemodialysis begins, the access is ready and there is no need to rely on a long-term catheter.

Q: Can an AV fistula be relocated if the existing one is problematic?
A: In many cases, if the initial fistula is severely compromised (e.g., blocked and irreparable), the vascular surgeon may consider creating a new fistula in another location, such as in a different arm or higher up, after assessing the condition of the blood vessels through a physical examination and ultrasound. However, each person has different anatomy and blood vessel quality, so the decision must be personalized.

Consult the vascular surgery team at Premier Jatinegara Hospital regarding AV fistula creation to plan a safe, strong, and durable vascular access.
 

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