Arteriovenous Fistula Creation
What the Examiner Expects
Surgical creation of a direct connection between an artery and vein in the arm for chronic hemodialysis access. The examiner expects you to know the NKF-KDOQI guidelines recommending a 'fistula first' approach, the order of preference for fistula creation (distal before proximal, non-dominant arm first), and the Rule of 6s for maturation assessment. The radiocephalic (Brescia-Cimino) fistula at the wrist is preferred first, followed by brachiocephalic at the antecubital fossa, then brachiobasilic with basilic vein transposition. Preoperative vein mapping with duplex ultrasound is essential.
Key Examiner Focus Points
- Preferred vascular access for hemodialysis (fistula > graft > catheter)
- Radiocephalic (wrist) → brachiocephalic (elbow) → brachiobasilic (transposition) hierarchy
- Fistula needs 6–8 weeks to mature before use (Rule of 6s: > 6 mm diameter, < 6 mm depth, > 600 mL/min flow)
- Steal syndrome: hand ischemia from arterial flow diversion — can require ligation or DRIL procedure
- Preserve arm veins early in CKD patients — avoid venipuncture and PICC lines in the non-dominant arm
Common Curveballs
6 weeks postop, the fistula has not matured — it is small and has a weak thrill
Obtain a fistulogram to identify the problem. Common causes of failure to mature: juxta-anastomotic stenosis, accessory veins stealing flow, or central venous stenosis. Juxta-anastomotic stenosis can be treated with balloon angioplasty. Accessory veins can be ligated to redirect flow through the main outflow vein.
Patient develops hand pain, coldness, and numbness after brachiocephalic fistula creation
Steal syndrome — arterial blood is preferentially flowing through the low-resistance fistula rather than to the hand. Mild steal: observe, hand exercises. Severe steal (rest pain, tissue loss): surgical intervention — DRIL procedure (distal revascularization-interval ligation) or banding/plication of the fistula to reduce flow.