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Post operative assessment for A-V
fistula
TL LUK
Consultant Vascular Surgeon
Sarawak General Hospital
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Post OP assessment
• Why ?
• When ?
• What ?
• How ?
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Reason for post op assessment
• Monitor maturation
– Detect early failure
– Intervene in fistula that are failing to mature
– Mature fistula ready for cannulation
• Recognise complications
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Timing of Assessment
• 3 days post surgery – Wound check
• 2 weeks post surgery – Assess and monitor maturation
• 6 weeks post surgery – Assess and monitor maturation
– Signed off if ready for haemodialysis
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Assessment
• LOOK
• FEEL
• LISTEN
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LOOK
• Incision site
– signs of infection, bruising, haematoma
• AV fistula
– presence of dilated veins
– Assess diameter and depth
– Assess complications
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Feel
• Thrill (continuous purring/vibration)
• Fistula compressible & non pulsatile
• Vein collapse on elevation
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Listen
• Auscultate using stethoscope
• A continuous low pitch bruit
• A high pitch bruit or whistle sound may
indicate stenosis
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Ultrasound assessment
• Direction of flow
• Can detect stenosis
• Size of vessel
• Depth of access
• Marking of skin over vessel
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Common complications
• Thrombosis
• Failure to Mature
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Early thrombosis
• Inadequate selection
– Small vessel size
– Central stenosis
• Surgical technique
• Hypercoagulopathy
• Hypotension
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Later thrombosis
• Stenosis/intima hyperplasia
• Poor cannulation technique
• External compression
• Central stenosis
• Hypotension
• Hypercoagulopathy
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maturation
• A fully matured AV fistula is one that can
sustain 3 consecutive 2 needle cannulations
with no infiltrations
• A mature AV fistula must be superficial
enough and large enough, thick-walled,
straight enough and have sufficient blood flow
to premit routine safe 2 needle cannulation
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Isometric Exercise post Op
• Increase blood flow and help develop the vein
• Build the muscle below to help make the vein
more prominent
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Maturation Time
• Usually 6 – 8 weeks
• Varies with individual
• Varies with type of A-V Fistula
• Investigate if not maturing
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Rule of 6s
• > 600 ml/min flow
• > 6 mms in diameter
• > 6 cm in length
• < 6 mms below skin
surface
• Examined 6 weeks
post creation
Is This an Easy Access to Needle?
On inspection it looks easy? But is it?
80
Brachio-cephalic AVF
AVF Needling: Just a Nice Picture
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Other complications
• Steal Syndrome
• Venous Hypertension
• Bleeding
• Infection
• Stenosis
• Aneurysm
• Cardiac failure
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Steal syndrome
• Collection of symptoms ending with hand
ischaemia.
• Inadequate blood supply to the hand distally –
the AVF ‘stealing’ blood away from the
extremity.
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Steal syndrome
AVF Post-creation Complications: Steal Syndrome & Venous Hypertension
Steal Syndrome• Affected hand may be blue (no blood
to fingertips. • No edema is present. • May have wounds.
Venous Hypertension• Affected hand may be red.• Edema is present .• As the hand swells, skin may breakdown.
31
• Pain/numbness in fingers
or hand
• Discoloration
• Cold to touch
• Delayed nail bed capillary
refill
• Loss of function
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Steal Syndrome
• Occur in 5% of
vascular access
patients
• Mostly those with
diabetes and
peripheral vascular
disease (PVD)
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Venous hypertension
• Congestion due to
outflow vein stenosis
• Usually central vein
stenosis
• On examination – Non collapsible pulsatile
vein
– Swollen upper extremity
AVF Post-creation Complications:Steal Syndrome & Venous Hypertension
Where Steal Syndrome causes problems Source of Venous Hypertension
32
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Venous hypertension
• Affected hand maybe red
and swollen
• Whole upper limb
oedema
• More common in
previous central catheter
insertion
• 14% unrelated
AVF Post-creation Complications: Steal Syndrome & Venous Hypertension
Steal Syndrome• Affected hand may be blue (no blood
to fingertips. • No edema is present. • May have wounds.
Venous Hypertension• Affected hand may be red.• Edema is present .• As the hand swells, skin may breakdown.
31
AVF Post-creation Complication:Venous Hypertension
37
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Infected bleeding false
aneurysm
Stenotic lesion
AVF Maturation:Assessory Vessels & Embolization
73
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• “SLEEVE UP” may reveal more than a nicely developing accessory vessel …
• It may also reveal a serious complication.
• This sleeve stayed down for several months without a peek. The vessel had not yet been used.
• This speaks very strongly to the value of nurses being dedicated to VA monitoring.
AVF Needling: Watchful Eyes
Aneurysm Enlarging Aneurysm
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cardiac failure
• Excessive shunting of blood
• Worse in anaemia, cardiovascular disease
• Leads to LVH, cardiac failure & coronary
ischaemia
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Cardiac failure
• Symptoms:
– Tachycardia
– SOB
– Creps
– Oedema
– Distended veins
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summary
• Why – Monitor maturation, Recognise complications
• When – 2 & 6 weeks
• What & How – Clinical – Look, Feel, Listen
– Ultrasound Scan
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