This document discusses arterio-venous (AV) fistulas which are surgically created shunts used for hemodialysis. Native fistulas in the lower arm are better than grafts or those in the upper arm. The most common problems with fistulas are stenosis which can cause poor development, difficult needling, or inadequate dialysis. Treatment options for stenosis include angioplasty using standard, high-pressure, or cutting balloons as well as surgery. Angioplasty is highly successful if performed correctly using high pressure and long inflation times to address recoil, and maintaining dialysis access is an important role of interventional radiologists.

1. Haemodialysis Fistula Intervention
Dr Ralph Jackson
Freeman Hospital
Newcastle-upon-Tyne

2. What are Arterio-Venous
fistulae?
• Surgically created “end to side” shunts
which allow dialysis.
• Lower arm (radio-cephalic) better than
upper arm (brachio-cephalic, brachio-
basilic, brachio-brachial).
• Native better than grafts (PTFE, bovine
ureter)

3. Anatomy

5. Typical AV Fistula
“Arterial” needle
“Venous” needle
Thrill

6. Typical AV Fistula
Arterial pressure
Venous pressure

7. Problems with fistulae
• Poor development
• Difficulty needling
• Inadequate dialysis
– Low flow rates
– Recirculation
• High pressures and prolonged bleeding
• Thrombosis
• Almost all due to stenoses which are
recurrent

8. Flat AV Fistula: peri-anastomotic
stenosis
“Arterial” needle
“Venous” needle
Weak thrill

9. Pulsatile AV Fistula: stenosis away
from anastomosis
Flat
Remote Thrill
Pulsatile and high pressure

10. Recirculation
“Arterial” needle
“Venous” needle
Thrill

11. Treatment options
• Angioplasty
– Standard balloon angioplasty
– High pressure balloon
– Cutting or scoring balloon
• Surgery
• Refashion anastomosis
• Patch stenosis
• Higher fistula
• Whichever way, get on with it.

12. Balloon angioplasty
• Big enough
– Tendency to use too small balloons
• High or ultra high pressure
– Standard RBP of 15Atm @8mm
• Inflation handle (obviously).
• Long inflation times as recoil common.
• Rupture uncommon but be prepared

13. Antegrade transvenous

15. Retrograde transvenous

16. Transarterial

17. Standard pressure balloon

18. High Pressure

19. Cephalic arch stenosis
 Much commoner in dysfunctional brachio-
than radio-cephalic fistulae (~50%).
 More prone to rupture and restenosis
 Primary patency rates at one year after
angioplasty only around 30%

21. Rupture management
• Not that frequent to have major rupture (1-
2%).
• Tamponade with long low pressure
inflation
• Covered stent as bail out
• Associated with subsequent loss of fistula

22. Balloon Tamponade

23. Covered stent/stent graft

24. Covered stent/stent graft

25. Covered stent/stent graft

26. Covered stent/stent graft

27. Covered stent/stent graft

28. Conclusion
• AV fistulas are simple to understand.
– History and examination are diagnostic.
• Most problems are due to stenosis.
• Angioplasty is highly successful if done
right.
• Stenoses recur so you will get to know the
patients well.
• Maintaining dialysis access is one of the
most important IR jobs.