Fistula failing to mature


#1

I have been on HD for a about 4 months having lost the race while waiting to organise a live donor transplant. Consequently I am receiving dialysis via a tunneled catheter 3 times a week for 5.5 hours.

My backup to the transplant is to have nocturnal home HD. There has been to attempts to have a radiocelaphic formed in my left arm which have failed. From my surgeon, my vein is of a good size although has calcification and the artery is on the narrow side.

My question is, is there any way to further attempt to form the fistula in the same place or is it time to move further up the arm. I would far prefer the radiocelaphic site as I think it is the best site should I end up doing home Nocturnal.

I am a 54 year old chap, non diabetic and gave no other chronic conditions.
Thanks in advance


#2

Unfortunately, Grant, this question demands a range of ‘touch, see, feel, and listen’ information that can only be obtained by seeing your arm, plotting your vessels, and understanding the physical features of your arm(s) and its/their anatomy.
Answering generically though …

Although I would agree that a forearm radio-cephalic is the access of preference, we have had many patients at home with upper arm fistulae … preferably brachiocephalic as a brachio-basilic is a less comfortable option for the patient and the needles are more difficult to stabilise on the inner aspect of an upper arm. Upper arm fistulae are just fine for home if a radio-cephalic cant be created. You would join a large minority! Transposition is a trick that often works for the upper arm … but this is a decision for your vascular surgeon and again depends on local anatomy.

Sometimes, trying to join the cephalic vein in the forearm, though not at the wrist (as is usual) but further up the forearm before the deep fascial ‘dive’, is a useful trick if the wrist site proves problematic.

Don’t forget your non-handed arm. Most of us (me included) feel they are klutz’s with their non-handed hand. I am right handed. I can’t write left handed, I can’t throw. I am useless on that side. But, that is primarily because I am comfy using my right, and preference it. But, people can be trained to be ambi- or opposi- dexterous, with a bit of practice! So, there is ALWAYS the other arm!

Not that I think it a likely good idea in your case, but we have also had two or three home patients with leg femoro-femoral fistulae, though again, these are nowhere near as easy to manage.

Finally, and while permanent catheters are not our preferred option, we would view is as far better to be at home with a catheter than in a centre with one! No-one will look after your catheter as well as you, and there is good data from Chris Chan’s Canadian group that shows that while the infection rate is higher with catheters than with fistulae, the overall complication rate with a catheter at home was significantly less than with a catheter in centre … https://www.sciencedirect.com/science/article/pii/S0085253815521248 … so … if you DO end up with a catheter, you’re STILL better off being home.

As to answering specific questions about whether or not further attempts can be made at your current failed site … no, that needs vision and hands-on to answer.


#3

Doctor Agar,

Thank you for your prompt and detailed reply. Although you could not definitively answer my question, you gave me plenty of information to go on with.

You are obviously a fine chap.

Thanks again.


#4

Along with Dr Agar advice let me lend some points that i have work with and see in the last 23 years as a master cannulalter,vascular access nurse. If you have seen the vessel wall of weight lifters you see they have big veins , which you can do to to bulid up your vessels for dialysis, There is a new produted that is waiting FDA approval it is called ( fist assis) google to find out more. Until then start lifting weights 5 pds or 10 you choice to increase the size of your fistula, Even if you now have a fistula it does not hurt to lift weights 4 to 5 times a day to blood kept and maintain blood flow


#5

Thanks for the reply. I am now the proud owner of fistula in the crook of my left elbow. My people want to start using it in a few days. It will be 7 weeks post formation by then.
I would happily consent however my transplant is firming up to happen in a month. My concern is that I may get lesser clearance in that time than I would with my tunneled catheter and I want to be as healthy as I can for the op.
I clearly understand that the fistula is the way to go for many reasons but I would like some advice as to which way to go.
Thanks.


#6

Any fistula, any time, should whip any catheter, anywhere. If its ready, if it de-pressurises on elevation above your head, and ‘looks’ good … better it than a catheter any day.


#7

Once again, thank you good Doctor. It’s now an easy decision.


#8

I have read all answers here …my opinion based on experience seen between 80 persons on dialysis center as patient too its… fistulas are non good for all due of luck of healthy, very thin and non strong veins. So other access methods are the alternative, such permanent catheter or graft. So, your fistula will NEVER work properly. Hope you will have a kidney transplant very soon !!!