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Preparing for Dialysis (AV Fistula)

  • A procedure that connects an artery to a vein in preparation for dialysis
  • For patients with failing kidneys, this procedure creates an access point for the dialysis machine
  • An AV fistula is a good long-term solution for dialysis, but some alternatives exist
  • Involves Vascular & Endovascular Surgery, Chronic Kidney Disease Program, and nephrology
Photo by Robert A. Lisak

Overview

Dialysis is a common treatment for people whose kidneys are functioning poorly. Taking over the work of the failing kidneys, a dialysis machine filters out toxins from the blood in people who have end-stage renal or kidney disease. To undergo dialysis, a patient must first have a surgical procedure to create an access point for the machine. This is typically done in the arm or the wrist, most often by connecting an artery and a vein. The procedure is performed by a vascular surgeon who specializes in treating the circulatory (vascular) system.

“Once the diagnosis of end-stage renal disease is reached, the option of dialysis should be discussed,” says Kristine Clodfelter Orion, MD, a Yale Medicine vascular surgeon and assistant professor of surgery at Yale School of Medicine. “The longest-lasting and best type of dialysis access is an arteriovenous fistula, or AV fistula.”

 At Yale Medicine, our vascular surgeons use the newest vascular surgery approaches for patients who need an access point for dialysis. They are also widely known for being at the forefront of researching the best surgical techniques for this procedure.

What is an AV fistula?

An AV fistula is a connection that’s made between an artery and a vein for dialysis access. A surgical procedure, done in the operating room, is required to stitch together two vessels to create an AV fistula. The access point must be durable enough to withstand dialysis treatment several times a week without collapsing.

At Yale Medicine, we lead research into the most effective surgical techniques to create AV fistulas. Our focus right now is on radial cephalic fistula—which is the hardest AV fistula to create. It is achieved when the surgeon connects the radial artery and the cephalic vein in the patient’s wrist. There are other surgical configurations as well, usually created in a patient’s forearm. If you undergo this procedure, the surgeon will work with you to choose the best option for you.

AV fistula surgery takes a few hours and is generally an outpatient procedure. It can be done under general anesthesia or through a numbing of the arm.

How is an AV fistula used during dialysis?

An AV fistula is how patients are connected to a dialysis machine. A nurse starts your dialysis treatment by inserting two needles into the AV fistula. One needle removes the blood and sends it to the machine, where it is filtered.  The second needle allows the blood to be safely returned to the body. Each dialysis treatment takes three to four hours, and generally patients need three treatments a week. 

When does AV fistula surgery take place?

The surgery is performed approximately six months before the first session of dialysis. It can take several weeks for the AV fistula to heal and become sturdy enough to withstand the rigor of dialysis treatments. Over the weeks following surgery, the high-pressure blood flow from the artery stretches the walls of the vein. As the vein stretches, it enlarges. The result is a long-lasting access point that allows the dialysis nurse to easily connect the patient to the dialysis machine.

Are there alternatives to AV fistula?

AV fistula is the best way to receive dialysis because it’s a long term solution for dialysis patients and carries a low risk of infection. However, there are several alternatives worth considering.  If you do not have a vein of sufficient size for an AV fistula, an artificial vein may be installed via AV bypass graft surgery. If immediate dialysis is required, a dialysis catheter can be inserted in a vein until a longer-term solution is created. At Yale Medicine Vascular & Endovascular Surgery, our surgeons are dedicated to finding the best dialysis access option for you.

What distinguishes Yale Medicine?

Our vascular surgeons are internationally recognized for their development of  new techniques for dialysis access. They work closely with the nephrologists, who diagnose and treat kidney disease, and interventional radiologists, who provide minimally invasive image-guided diagnosis and treatment of disease. The result is a course of treatment that fits the needs of each patient.