An arteriovenous fistula is a connection or passageway between an artery and a vein surgically created for hemodialysis treatments.

1. ARTERIO-VENOUS FISTULAE
USING GRAFTS
BY
DR. MUHAMMAD SAIFULLAH
POST-GRADUATE RESIDENT
DEPARTMENT OF UROLOGY AND RENAL
TRANSPLANTATION
PMC/ALLIED HOSPITAL, FAISALABAD.

3. INTRODUCTION
» Establishing and maintaining
hemodialysis access is a cornerstone of
long term renal replacement therapy.
» Vascular access is an
ACCESS TO LIFE….

4. » 1944…… WJ Kolff
designed the first
practical dialysis machine
but was only used for
Acute Renal Failure
because of
repeated cutdowns.
» 1960…… Scribner,
Dillard, and Quinton
introduced the Teflon-
Silastic arteriovenous
(AV) shunt.

5. » 1966…… Subcutaneous AV fistula by
Brescia, Cimino, Appel and Hurwich.
» 1969 …… Autogenous Saphenous Vein
Loop was introduced by May, Tiller,
Johnston, Stuart & Sheilds.
» 1976…… Introduction of
polytetrafluoroethylene (PTFE) for bridge
fistulae.

6. ARTERIO-VENOUS GRAFT
» An AVG is created by joining a vein
to the artery using an biological (e.g.
Long Saphenous Vein, Bovine vein)
material or synthetic (e.g. PTFE).
» Also known as “BRIDGE FISTULA”

7. IDEAL AV Graft
» Easy to handle.
» Non-thrombogenic.
» Immunologically inert.
» Resistant to infection and puncture
trauma.
» Able to retain tensile strength.
» Manufactured at a reasonable cost.

8. Patency AVF vs AVG

10. AV Graft Formation Vs AVF

11. Why grafts are required?
» Repeated thrombosis after insertion of
shunts.
» Poor flow in AV Fistulae.
» Rejection of initially successful renal
transplant with thrombosis of fistula.

12. AV Grafts
Biological
Grafts
Human
Long Saphenous Vein
Autografts
Denatured homologous
vein allograft.
Cryopreserved saphenous
vein
Human umbilical vein
Bovine
Heterograft
s
Bovine Carotid Artery
Bovine ureter vascular
graft
Bovine mesenteric vein
Sheep Collagen Grafts
Biohybrid and
bioresorbable prostheses
Synthetic
Grafts

13. AV Grafts
Biological
Grafts
Synthetic
Grafts
Dacron Graft
PTFE Graft
Standard
Stretch
Expanded
(ePTFE)
Polyurethane
Polyether-
urethaneurea
(Vectra graft)

14. Biological grafts (Human)
1. Autogenous great saphenous vein graft
» Taken between groin and knee
» disappointing results with patency rates of 20%
at 2 years.
» Other sites include long saphenous V. from
ankle to knee, Cephalic vein from wrist to elbow,
Cephalic vein from Elbow to shoulder or external
jugular veins.
2. Denatured homologous vein allograft.
3. Cryopreserved Saphenous vein.

15. Biological grafts (Human)
4. Umblical Vein Graft.
» Successful dialysis for a period of 2 years
» Also prone to infection.
» Difficult to use and handle.

16. » Bovine carotid artery (removed from calf and treated
with FICIN to remove elastic and muscular material…..
A tube of collagen is left which is used for graft.
» Bovine ureter vascular graft (for patients with a history
of multiple failed synthetic grafts).
» Bovine mesenteric vein
1. Obtained by a patented process of gluteraldehyde
cross linking and gamma radiation)
2. Physiological properties similar to those of the
human saphenous vein due to its high elastin to
collagen ratio.
Biological grafts (Bovine)

17. » Sheep collagen grafts –
Formed from gluteraldehyde-tanned bovine
collagen grown around a polyester mesh.
» Biohybrid and bioresorbable prosthesis,
Graft pretreatment with endothelial cell
culture, methods of affixing antibiotics,
anticoagulants and growth factor to graft
surfaces.
Biological grafts (Bovine)

18. » DACRON:
The commonly used synthetic grafts include
Dacron. The fibrillar structure of Dacron was
expected to encourage tissue ingrowth and
provide greater durability for recurrent
cannulation. Not used on a wide scale.
Synthetic grafts

19. Synthetic grafts
PTFE
» Fluorocarbon polymer
» Prosthetic graft of choice
» Stretch expanded PTFE
(ePTFE) is preferable to
standard PTFE.
» Lower risk of disintegration
with infection
» Low thrombogenicity
» Low tissue reactivity
» Prolonged patency
» Improved surgical handling

20. Synthetic grafts
» POLYURETHANE

21. SITES FOR AV GRAFT

22. TECHNIQUE
Should be used to
connect the brachial
artery to a distal vein
in the forearm…..
Ideally
Or
Connect radial or
ulnar artery to a
proximally located
vein…... Alternatively

23. LOOP
CONFIGURATION
1. Oblique Incision in
Anticubital fossa
2. Identify Brachial Artery & a
Suitable vein
3. Mobilze upto 5 cm
distance
4. Opening the vein and
passage of Fogarty
catheter to confirm
patency.
5. Lay the graft over the
forearm and make the
incision over the base of
the course.

24. 6. Make subcutaneous
tunnels
7. Pull the vein through the
tunnel so that proximal
end is near the vein and
distal end near the artery.
8. 5000 IU heparin &
clamping the artery.
9. Longitudenal arteriotomy
is made
10.Vessel is anastomosed in
end to side fashion using
prolene 6/0.
11.Release the arterial clamp
and check for patency.
12.Anastomose the vessel
with the vein in the same
fashion.

25. Straight or J-Shaped
Configuration
1. Better arrangement than
loop.
2. Mobilize Brachial Artery
3. Mobilize suitable distal
vein.
4. Make a tunnel between
the two.
5. Anastomose the artery
first and then vein.
6. J-Shaped is best
hemodynamically.
7. Make the brachial artery
anastomosis below the
elbow crease.

26. Retrograde
Arterialization
Graft is taken from
the Ulnar Artery to a
suitable vein in the
anticubital fossa or
Cephalic vein in the
Delto-pectoral
groove.

27. THIGH GRAFTS
Loop configuration is
done by mobilizing the
Long Saphenous Vein
upto the knee and left
attached to the
femoral vein and
distal end is tunneled
subcutaneously for
attachment with the
femoral artery.

28. THIGH GRAFTS
If used as a straight
graft, it has to be
completely
removed, reversed
and sutured to the
femoral vein above
and the popliteal
artery below.

29. POST-OPERATIVE CARE
» Patient is heparinized for 24 hours.
» Check the graft regularly for patency
and bleeding.
» Keep arm elevated to reduce edema.
» Encourage hand and finger movement.
» Cephalosporins or Ampicillin with
cloxacillin should be given to cover
operation and continued thereafter 2-3
days.

30. COMPLICATIONS OF LONG
TERM ACCESS
1. Central vein stenosis/arm swelling
2. Thrombosis
3. Infection
4. Hematoma/bleeding
5. Aneursymal degeneration.
6. Pseudoaneursym of AV graft
7. Steal syndrome

31. CENTRAL VEIN STENOSIS / ARM
SWELLING
• Patients with extremity
edema that persists
beyond 2 weeks after
graft
• Evaluate patency of the
central veins
• Preferred treatment for
central vein stenosis is
PTA.
• Stent placement (Recur
inside 3 weeks, >50 %
elastic recoil of vein)

32. THROMBOSIS
» Can occur early or after months of use.
» If occurs early, re-explore and correct
the problem.
» If occurs late, thrombectomy is done
using Fogarty catheter # 2.
» Late thrombosis can be due to distal
stenosis. Commonly seen in PTFE graft
because of intimal proliferation at
venous anastomosis site.

33. INFECTION
 Commonly occurs with artificial grafts like
bovine, PTFE and umblical vein.
 Four times more common than infection
occurance in AV Fistula.
 Once graft is infected, no choice but to remove
it.

34. HEMATOMA / BLEEDING

35. ANEURYSMAL DEGENERATION
Occurs if vein is varicose or
used too early.
Can be repaired or excised
following the replacement of the
graft material.

36. HIGH VENOUS BACK PRESSURE
 Outflow obstruction
 Due to stenosis in the
draining vein
 Can be overcome by
passing fogarty
catheter per-
operatively to check
for venous
obstruction.
 Suspected when high
venous pressure is
noted during dialysis.
 Go for bypass graft to
bypass the stenotic
segment.

37. VASCULAR STEAL SYNDROME
» 1.6% to 8% of all individuals with a functioning
shunt.
» Risk factors include female sex, age > 60 years,
diabetes, arteriosclerosis, multiple operations on
the same limb, the construction of an
autogenous fistula, and most commonly the use
of the brachial artery as the donor vessel.
» Symptoms associated with the ischemic steal
syndrome range from vague neurosensory
deficits to ischaemic rest pain or tissue loss.

38. VASCULAR STEAL SYNDROME
» Classification:
Stage I, Pale/blue and/or cold hand
without pain.
Stage II, Pain during exercise.
Stage III, Pain at rest.
Stage IV, Ulcers/necrosis/gangrene.

39. VASCULAR STEAL SYNDROME

40. PSEUDO-ANEURYSMS