Purpose and suitability
The aim is to find and treat the narrowing that is throttling the access before it clots completely. Prompt fistuloplasty can restore dialysis performance, extend the life of the access and avoid an urgent thrombectomy or a new access operation. Where the access has already clotted, clot removal and fistuloplasty are combined in one sitting.
- Dialysis patients with signs of access dysfunction
- Abnormal surveillance findings from the dialysis unit
- A thrombosed fistula or graft requiring urgent salvage
Timing around dialysis sessions, anticoagulation and residual kidney function are factored into the decision, in liaison with the dialysis unit.
Signs of access dysfunction
Referral may occur because of low dialysis flow, high venous pressures, difficult needling, prolonged bleeding after dialysis, arm swelling, reduced thrill or failure of a fistula to mature.
Assessment and preparation
Preparation covers dialysis timing, anticoagulant and allergy review, and the specific clinical problem affecting the access. Contrast use is planned with kidney status in mind. Most patients need no fasting for a local-anaesthetic procedure, but follow the written instructions provided, and bring your usual medication list.
Coordination with dialysis
The procedure is planned around the dialysis schedule so fluid balance, anticoagulation and access use are coordinated safely. The dialysis unit may provide recent flow measurements or details of needling problems, which help target the investigation. When the access is thrombosed or dialysis cannot be completed, assessment may need to occur urgently rather than through a routine appointment.
How the procedure is performed
Fistulogram
After local anaesthetic, a small sheath is placed into the fistula or graft. Contrast is injected while X-ray images show the whole access circuit, including the central veins.
Fistuloplasty
A balloon is positioned across the narrowed segment and inflated. High-pressure, cutting or drug-coated balloons may be considered in selected recurrent lesions. A stent or stent graft is occasionally required when angioplasty is inadequate or the vessel is damaged.
Treatment of thrombosis
If the access has clotted, mechanical thrombectomy or thrombolysis may be combined with fistuloplasty to remove the clot and treat the underlying stenosis.
Recovery and follow-up
The puncture site is compressed or closed, and flow, puncture sites and hand circulation are checked before discharge. The access can often be used for dialysis the same day, depending on what was done. Report loss of the thrill, bleeding, increasing swelling, hand pain or fever promptly. Ongoing surveillance at the dialysis unit watches for recurrent narrowing, which is common and treatable.
Risks and possible complications
- Bruising and bleeding
- Vein rupture during balloon dilatation
- Clotting of the access
- Embolisation
- Infection
- Contrast reaction
- Hand ischaemia
- Recurrent narrowing needing repeat treatment
- Failure to restore usable access
Most procedures are completed without incident, and the alternative, losing the access entirely, usually carries greater consequence.
Alternatives and practical considerations
Surveillance, surgical revision or creation of a new dialysis access may be alternatives to fistuloplasty, depending on the location and severity of the narrowing and the overall condition of the fistula or graft. A procedure is generally recommended when impaired flow is affecting dialysis or threatening access patency.
A fistulogram defines the anatomy using contrast, and balloon angioplasty can treat a suitable narrowing during the same session. Stents are reserved for selected problems such as recoil, recurrent stenosis or vessel injury. Patients should understand which segment is being treated and whether the procedure is expected to restore function temporarily or provide a more durable solution.
Re-narrowing is common because repeated needle access and high blood flow continue to affect the vessel. Ongoing monitoring by the dialysis unit and vascular team remains necessary. Reduced thrill, poor dialysis clearances, difficult cannulation, prolonged bleeding or increasing arm swelling should be reported early, as treatment before complete thrombosis is usually simpler.
Fistulogram and fistuloplasty care at Yarra Vascular Surgeons
Yarra Vascular Surgeons provides fistulogram assessment and fistuloplasty with thrombectomy, stenting and surgical revision available in the same service, so the access problem can be dealt with definitively rather than referred on.
Arrange a vascular assessment
Falling dialysis flows, difficult needling, prolonged bleeding or access swelling can signal a stenosis. Early referral for fistulogram and fistuloplasty reduces the risk of complete access thrombosis.
