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Management of Arteriovenous Fistulas • Link to This Article Online for CPD/CME Credits Abul Siddiky,1 Kashif Sarwar,2 Niaz Ahmad,3 James Gilbert4

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Management of Arteriovenous Fistulas • Link to This Article Online for CPD/CME Credits Abul Siddiky,1 Kashif Sarwar,2 Niaz Ahmad,3 James Gilbert4 EDUCATION CLINICAL REVIEW Management of arteriovenous fistulas • Link to this article online for CPD/CME credits Abul Siddiky,1 Kashif Sarwar,2 Niaz Ahmad,3 James Gilbert4 1CRUK/MRC Oxford Institute for The global incidence of patients requiring renal replace‑ SOURCES AND SELECTION CRITERIA Radiation Oncology, University of 1 Oxford, Oxford, UK ment therapy is increasing. In 2012, 108 per million We searched Medline, the Cochrane Database of 2 Leeds City Medical Practice, adults in the United Kingdom started renal replacement Systematic Reviews, and Clinical Evidence online using the Leeds, UK therapy, with a prevalence of 861 per million population.2 3 search terms “arteriovenous fistula”, “vascular access for Leeds Teaching Hospitals NHS Haemodialysis is one of three viable options for renal Trust, Leeds, UK haemodialysis”, or “renal replacement therapy” for articles replacement therapy alongside renal transplantation and 4Oxford University Hospitals NHS published between 1990 and 2014. Whenever possible we Trust, Oxford, UK peritoneal dialysis. In 2012 in the United Kingdom, 20 332 focused on systematic reviews, meta-analyses, and high Correspondence to: A Siddiky adults were receiving haemodialysis, accounting for 42.7% quality randomised controlled trials. We also consulted [email protected] of all renal replacement therapy and 2.3% more patients the UK Renal Association guidelines (2011) and the US Cite this as: BMJ 2014;349:g6262 than in the preceding year. This is a worldwide problem, National Kidney Foundation Kidney Disease Outcomes doi: 10.1136/bmj.g6262 with a little over 370 000 people in the United States and Quality Initiative guidelines (2000). approximately 10 500 people in Australia and New Zea‑ thebmj.com land also receiving haemodialysis.3 4 The purpose of this arteriovenous grafts. Unlike catheters and synthetic grafts, Previous articles in this review is to provide non‑specialists with an overview of arteriovenous fistulas are created from native tissue and series arteriovenous fistulas and potential complications. thus avoid the problems from using foreign material, and • The diagnosis and they are superior in areas such as complication rates, lon‑ management of hiatus What is an arteriovenous fistula? gevity of the access point, and greater blood flow (box 1).7 hernia An arteriovenous fistula is a direct connection between The cost of maintaining an arteriovenous fistula is only one (BMJ 2014;349:g6154) an artery and a vein, created surgically or occurring as a eighth of that for an arteriovenous graft.8 The infection rate • The management of result of pathology. Surgically created fistulas were first associated with an arteriovenous fistula is up to 10 times teenage pregnancy described in 1966 following observation of the ease of lower than that of any other form of vascular access and 9 10 (BMJ 2014;349:g5887) phlebotomy and relatively unaffected health of Korean has a considerably better prognosis. Patients with an war veterans with traumatic fistulas in the 1950s.5 6 arteriovenous fistula are less likely to require medical inter‑ • Laryngitis 11‑13 (BMJ 2014;349:g5827) The principal indication for surgically created arterio‑ vention than those with an arteriovenous graft, with one venous fistulas is to provide access for haemodialysis, a study showing 0.2 interventions versus 1.0 intervention per • Managing the care process that uses the patient’s blood flow to remove waste patient per year, respectively.13 Arteriovenous fistulas show of adults with Down’s products such as urea, creatinine, and excess water from better survival of long term access than do arteriovenous syndrome the blood. Ordinarily these waste products are dealt with grafts,8 with approximately 90% versus 60%, respectively, (BMJ 2014;349:g5596) by the kidneys but accumulate during kidney failure (figs accessible at one year.14 • Managing common 1 and 2). In the United States, the Fistula First Breakthrough Ini‑ symptoms of cerebral tiative is a promotional drive for fistulas to become the palsy in children Why are arteriovenous fistulas used for haemodialysis? preferred choice for vascular access for renal replacement (BMJ 2014;349:g5474) Successful haemodialysis requires a reliable access point for therapy.15 Since the creation of the initiative in 2003, the connection to the dialysis machine, with high volume flow, use of arteriovenous fistulas has on average increased by access to superficial veins (<1 cm from the skin surface) 3.3% annually alongside a concomitant decrease in the for cannulation, and dilation and strengthening of veins to long term use of central venous catheters.16 enable repeated cannulation. Using an arteriovenous fistula UK guidance is equally supportive for preferential use for haemodialysis offers the best short, intermediate, and of arteriovenous fistulas for haemodialysis. Guidelines long term options for renal replacement therapy over other from both the Renal Association17 and the National Insti‑ types of vascular access, such as catheters and synthetic tute for Health and Care Excellence18 propose that 65% of SUMMARY POINTS The number of patients requiring haemodialysis is increasing worldwide Arteriovenous fistulas provide the ideal means to achieve vascular access for haemodialysis Such fistulas are generally well tolerated Complications include infection, thrombosis, stenosis, aneurysmal change, steal syndrome, and high output cardiac failure An arteriovenous fistula effectively acts as a patient’s lifeline and therefore should be looked after carefully Fig 1 | Brachiocephalic arteriovenous fistula 24 1 November 2014 | the bmj EDUCATION CLINICAL REVIEW Box 2 | Advice for patients with a newly created arteriovenous fistula • Protect against direct trauma to the arm or fistula in the first few days • Avoid overuse of the arm with the arteriovenous fistula • Do not drive or lift heavy objects for the first two weeks • Carry out strengthening exercises, such as squeezing a rubber ball for 2-3 minutes 2-3 times each waking hour in the first few weeks Box 3 | Advice for patients on the long term care of an arteriovenous fistula • Maintain cleanliness around the puncture site and skin surrounding the fistula • Check for “thrill” and listen for bruit daily • Avoid falling asleep on the affected arm • Avoid tight fitting clothes, jewellery, or watches on the affected arm Fig 2 | Arteriovenous fistula all incident cases of haemodialysis (65% of all new start‑ being used for haemodialysis Box 4 | Order of preference for vascular access ers each year) and 85% of all prevalent cases (85% of a 1. Arteriovenous fistula: radiocephalic then brachial- unit’s haemodialysis population) should receive dialysis cephalic then brachial-basilic transposition through an arteriovenous fistula. 2. Arteriovenous graft 3. Tunnelled venous catheter How are arteriovenous fistulas looked after and used? 4. Non-tunnelled catheter Patients can take several measures to improve the matu‑ ration and longevity of their arteriovenous fistula (boxes risk of infective complications with buttonhole access.23 2 and 3).19‑21 As soon as an arteriovenous fistula has A cohort study of 90 patients who received haemodialysis been created, overuse, driving, and heavy lifting should at home also found an increase in infective complications be avoided. Patients are also advised to protect the arm (incidence rate ratio 3.85). A systematic review by the from direct trauma. Long term care concerns maintaining same authors further supported this finding.24 Conse‑ cleanliness; carrying out strengthening exercises, such quently, some haemodialysis units have opted to avoid as squeezing a rubber ball; and avoiding exposure of the the buttonhole approach. arm to tight fitting clothes, jewellery, and watches. Blood flow in the fistula can be assessed by palpating What are the alternatives if an arteriovenous fistula is not for a thrill and listening for a bruit. To identify a thrill, possible? the fistula is palpated along its length with at least three When haemodialysis is initiated, the clinical team will fingers or the upper palm of the hand, and a continuous in most cases decide to use an arteriovenous fistula first vibration or buzz can be felt. A bruit can be auscultated and consider other devices for vascular access if that is with a stethoscope at the same time. The strength and not a viable option; all access types should be routinely quality of thrill and bruit differ from patient to patient, discussed with the patient. Initial creation of an arterio‑ and patients are the best judge of whether there has been venous fistula is done as distal as possible in the non‑ a change. Most changes in thrill and bruit will have been dominant arm and moved progressively proximal, moving identified in the dialysis suite, but it would be recom‑ to the dominant arm if options become exhausted. Box mended that the patient’s general practitioner check for 4 gives an order of preference for vascular access.17 25‑ 27 these on every visit, as examination is quick and easy to However, there are potential but not absolute contrain‑ perform. Healthcare professionals should avoid using the dications to the creation of arteriovenous fistula. These arm with the fistula. If necessary, however, blood can be include pre‑existing severe peripheral vascular disease, Box 1 | Superiority of taken from veins in the back of the hand on the affected cardiac failure, and amputation of the relevant arm. arteriovenous fistulas arm. The main alternative to haemodialysis
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