I have a AV fistula created June24/09…on the upper left arm.The first fistula on the wrist did not work. The fistula is very deep and they have to use extra long 1¼" needles at a 90° angle to just reach the fistula.The flow rates were tested but I have no numbers…I passed the first test and failed the second…I have very little bleeding post dialysis. My problem is delayed needle pain. A half hour after the needles are inserted the sites begin to burn,sting and a throbbing pain begins and the pain increases each moment so that the needles have to be removed as I am in agony and the tears roll down my face. My vascular surgeon says he has never heard of this so he can’t help me. I am at my wits end as what to do.I need some answers as I will not continue this way.
Needle,
How long have you been using the Fistula
What blood flow do you use?
Do you use sharps or buttonhole needles (dull)?
thanks
The first comment I must make – it almost has to preceed every response I make – is that without knowing you as an individual, and without knowing your fistula, it’s peculiarities, its shape, length, depth and flow patterns, any responses I make must be taken generally and not necessarily specifically applicable to you as an individual.
It appears that your fistula is still young, having been made less than six months ago and in the upper left arm. I am making the assumption that it is a native (not graft) brachiocephalic fistula with the cephalic vein tracking straight up over the top of your bicep muscle. Some veins are deeper than others and deeper fistulas can sometimes be more difficult to cannulate then more superficial ones – this may mean that a second procedure needs to be done in some deeper fistulae to superficialise them. Now - for a moments’ indulgence in anecdote: One patient I remember who did have a “superficialisation” procedure then had local nerve entrapment in the scar tissue around the superficialised vein with pain in the local area of needle insertion, Surgical division of the nerve solved the problem … but gee, that has to be rare. I cannot see that as a likely issue unless you have had superficialisation done (and if so, it might be a rare possibility for the surgeon to consider).
Some fistulas are as straight as a superhighway while others wiggle and turn, dip and rise. Further, the anatomy of the vein includes, as a perfectly normal structure that should be there but sometimes gets in the way, a series of valves And, especialy if the area for inserton is limited and a vein valve just happens to be there, in the limited section available, these can cause needling difficulties and symptoms as well (see more on this later).
Firstly, a young fistula can cause trouble – indeed, this is a frequent problem.
Most experts believe that a ‘maturation’ period of 2 to 3 months (or, better, more) is the best before a fistula is used. Now, it is true that, especially in some places in the EU, some nephrologists and dialysis services advocate the use of a newly created fistula very early – within a week or two of creation. This is not the usual practice, however, in the US, Canada, the UK or Australia. In these countries, an 8 to 12 weeks maturation phase is recommended wherever possible. ‘Maturation’ means allowing the vein wall to thicken, toughen and strengthen. The vein wall is an already thin and stretchy structure, so when it is joined to an artery – as it is when a fistula is created – the vein is suddenly subjected to high pressure and high flow – which is not normally designed to withstand. These pressures and flows from the newly attached artery stretch up the vein, stretching the vein wall so much that the vein wall becomes thinner. Think of a balloon as you blow it up – the rubber becomes tighter and thinner. Over time, the vein wall will respond tho the higher pressures and flows within it and ‘toughen up’, becoming thicker and stronger. This is a process known as “arterialisation”. It can take many weeks for this process to occur. Needling a fistula too early on in its maturation cylce means that the needle is being inserted into a still thinner-than-ideal structure which has not yet been “arterialised” and can thus be easily damaged (or can leak) in the process.
Early fistula needling risks “infiltration”. Infiltration means that blood leaks around the needle into the surrounding tissue. Most dialysis patients will have either had (or seen in an adjacent patient) a "needle blow”. A “blow” is where either there has been a major leak around the needle or the needle has actually slipped out of the vein. This leads to rapid bleeding into the tissues of the arm with swelling, pain and later bruising. These are very obvious when they occur.
Less obvious, however, is the infiltration that can occur by subtle leakage into the tissue around the vein wall from a needle placed through an as yet-too-thin vein wall. This causes infiltration at a microscopic (invisible to the eye) level rather than at the obvious “macroscopic” (visible to the eye) level of a fistula “blow”.
This may be what is occurring in your fistula.
It can be a real problem! To make matters worse, pain (and this low-level infiltration can be painful) breeds anxiety and anxiety breeds tension. Because it can’t be easily seen, you get told you are a ‘wooz’ and a ‘complainer’ … yet you are not. The pain is real. The presence or expectation of pain means that you sit there on dialysis – tense as all hell – waiting for the pain to come. Your arm and muscles are immobilised and stiff, your bicep tense … and these all increase the risk of infiltration and blood leakage – particularly so, muscle tension … … and so the problem self-perpetuates.
Though it is easier said than done, if you can relax yourself and allow your arm muscles to relax and your arm to move, allow your bicep to go floppy – this will actually make a difference. Some patients sit, stiff as boards, throughout dialysis. This is neither necessary nor advisable. The needled arm should be able to (and be allowed to) move, to readjust its position, to be a normal arm (or as close as is possible) during dialysis. It is true that, sometimes, movement can affect flows and pressures within the fistula and set off alarms – for example a high venous alarm or a low arterial alarm. This is actually not all that common and most patients can (and should) move much more freely during dialysis than they (or sometimes their nursing staff) think they can.
Try to relax. It really will help! And … yup … easier said than done, I know!
Despite all this, some patients will have pain with needling. One clear way around this problem is, in my view, the buttonhole technique.
I am a believer in the buttonhole technique – though it is not ideal for every patient. If a buttonhole is formed carefully by trained staff that adhere to the well-described practices of same site, same nurse, same angle insertion as described in countless dialysis literature (your own US “Fistula First” program details the buttonhole technique well), this technique rapidly and completely takes the pain out of dialysis needle insertion. If your unit uses and is familiar with this technique, it may be an answer to your problems.
We have occasionally encountered problems with vein valves, especially if the needle tip ends up being near one of them inside the vein. A high return rate of blood flow … this is not uncommonly 400-450ml/hr in the US, though other countries tend to use far lower blood flow rates (eg: 300-325ml/hr in Australia) as our far longer dialysis sessions (4.5-5 hrs) make up for our lower blood flow practices … can cause a “fluttering” of the valve. This, in turn, may induce vein wall spasm and pain. Lowering your blood flow rate to, say 300ml/hr might solve the probem. Why dont you see. Start at 300ml/min and stay there. See if the pain stays away. If it does – and it just might be the simplest answer of all – then you (1) have your answer but (2) would have to compensate with a longer session … and that, mind you, would be to your benefit, not to your loss!!
If the needles have been inserted at very similar (but not the same) sites each time – as they would be if you were using the buttonhole technique – a change to the insertion site can sometimes be therapeutic and solve the problem. Vein spasm can sometimes be treated with a not-too-hot hot pack – but not reliably so.
Again, consider the buttonhole technique.
Some have advocated needle “flipping” but this is not a practice I like or advocate and nor do the guidelines of the US Fistula First program. I certainly don’t see this as a solution to your problem.
I do not have information regarding the flow characteristics of your fistula. If there is an up-stream stenosis – a obstruction or a narrowing in the vein between the where the needle is and your heart – this can lead to back-pressure, to a raised venous pressure, to a greater risk of infiltration of the tissues around the needle where it enters the vein and, thus, to pain or spasm (especially at the venous needle site). On the other hand, a lower feed-pressure from a narrowed or stenosed arterial anastamosis (the join between the artery and the vein) may lead to lower flows in the fistula and thus, some ‘’sucking” of the needle against the vein wall (in particular, the arterial needle) and it it is the arterial needle that is hurting, this might be a possible problem. This would normally show as a low arterial feed-pressure and be evident on the arterial needle pressure dial of your machine.
Either of these problems can promote problems and occasionally discomfort in the fistula. Most units now routinely use either a Transonic™ or similar fistula monitoring and surveillance system. These routine tests (we stream all our patients through a Transoni assessment on a 3 monthly basis) ought to pick up issues with flows and pressure. I am assuming that, as you have not alluded to pressure and flow problems, fistula surveillance has been done and no issues found.
At the end of the day, the solutions to your problems may lie in consideration of the buttonhole technique – if this has not already been suggested. Without knowing your specific fistula, however, I can probably go no further and, of course, not knowing your specific fistula means that all I have written may not apply to you and, at least from your point of view, be simply prattle!
I can only reassure you that most of these problems can be sorted out … so dont throw in the towel. Press for a solution, yes, but not for capitulation.
Finally, if your pressures and flows are not known, this would be something that could perhaps be organised so that the dynamics of the fistula are known.
I hope that this has been of some assistance to you.
John Agar
Thank you for the quick response and the very detailed answer. I go to dialysis today and will ask for the flow rate numbers. I have seen the vascular surgeon 3 times and each time he refuses to listen and basically blows me off. His rudeness and dismissive attitude leave me speechless. I am apprehensive about going to him again without some facts to back me up.
Thanks again…
Aha
You have given the most important answer to the problem … the fistula is very deep and they have to use extra long 1¼" needles at a 90° angle to just reach the fistula …
It sounds like you need superficialisation. No - doesnt sound like - sounds certain (at least it does from this distance!).
And - it is common to have to do a 2 stage superficialisation procedure in AVF surgery.
It isnt ‘cricket’ (or is that too Australian) to dive a needle down at 90 degrees … then try to straighten it up and ‘force’ the AVF (and its contained needle) back towards the surface - with all the tissue stress and ‘tug’ that will cause. That’ll ache like anything!
I think you have self-solved.
It sounds to me as if the AVF is too deep (not your surgeons fault in construction, mind, but just the way your anatomy is … or was) and your nurses are having to try to ‘dig it up’ back towards the surface, each dialysis. No wonder it aches as the dialysis progresses.
Dont be alarmed … surgical superficialisation is common. This is especially so in upper arm AVF.
There are several surgical ways to bring a vein surgically closer to the surface … though I stress that I am NOT a surgeon (I tend to faint at the sight of blood!) … but if it needs to be done, it also needs to be done in such a way as to avoid a deep dive at the proximal (heart) end of the AVF after the superficialised segment - else a stenosis is later likely to result.
John Agar
[QUOTE=John Agar;19007]Aha
You have given the most important answer to the problem … the fistula is very deep and they have to use extra long 1¼" needles at a 90° angle to just reach the fistula …
It sounds like you need superficialisation. No - doesnt sound like - sounds certain (at least it does from this distance!).
And - it is common to have to do a 2 stage superficialisation procedure in AVF surgery.
It isnt ‘cricket’ (or is that too Australian) to dive a needle down at 90 degrees … then try to straighten it up and ‘force’ the AVF (and its contained needle) back towards the surface - with all the tissue stress and ‘tug’ that will cause. That’ll ache like anything!
I think you have self-solved.
It sounds to me as if the AVF is too deep (not your surgeons fault in construction, mind, but just the way your anatomy is … or was) and your nurses are having to try to ‘dig it up’ back towards the surface, each dialysis. No wonder it aches as the dialysis progresses.
Dont be alarmed … surgical superficialisation is common. This is especially so in upper arm AVF.
There are several surgical ways to bring a vein surgically closer to the surface … though I stress that I am NOT a surgeon (I tend to faint at the sight of blood!) … but if it needs to be done, it also needs to be done in such a way as to avoid a deep dive at the proximal (heart) end of the AVF after the superficialised segment - else a stenosis is later likely to result.
John Agar[/QUOTE]
Thank you so much for your diagnosis.It got me an appointment with the other vascular surgeon and next Tuesday he is going to operate on my fistula to bring it up to the surface. He was surprised at how deep it really is. Thank you again for your help.
Dear Needled88
That sounds good news. Sometime down the track, let me know if superficialisation solved your problem. I think it will … well, I hope it does … but I’d be interested to know. Deep AVF are a common problem and superficialsation is usually easy, swift and problem-solving.
John Agar
I had to change the surgery date to Jan29th because the surgeon who didn’t want to help me is scheduled for surgeries next Tuesday.I won’t be able to use my arm for 6 weeks after but I will let you know how things go. Thanks again…
To tell the truth, we usually use them as soon as any operative swelling has subsided - and if there isnt much (= often the case depending on how the superficialisation is done - ie: by longitudinal incision or by skip incisions), we can often use them immediately - or at least by the next scheduled dialysis.
That allows us to avoid an IJ catheter … something we try to do as often as we can.
OK … it doesnt always pan out that we avoid alternative access - but it does, most of the time. One of our vascular surgeons prefers longitidinal incisions - and they more frequently need alternative access as there is a bigger scar and more post-operative swelling. Skip incisons … at right angles to the vein x 2 - 4 up the length (depending on the length needing lifting) end up causing less swelling.
Both techniques are good.
The vein is already 'arterialised - the AVF has been there since August - so there is no maturation time needed - just skin and superficial tissue recovery time.
John Agar
I still have my chest lines which are being used now…having given up on the arm a few weeks back. I was told it would be 6 weeks before the arm can be used but we will find out after the surgery. Thank you for all your information and for keeping in touch.
Dear Needled
I have been wondering …
Some time back (see earlier posts in this thread) I thought the main reason behind your fistula pain was that the fistula was ‘too deep’ - you were having to use 1 1/4" needled to reach it - and you had a time-slot to have it superficialised …
Did you have that done?
Did it fix the problem?
Perhaps you could give a ‘follow-up report’.
John Agar
http://www.nocturnaldialysis.org
Hi Dr. Agar…I have had so much trouble logging in…so I had the surgery and have been needled twice now with 2 needles and all is going so well. I have not had that throbbing pain reoccur…what a relief. Definitely the pain had to be from the nerves with the needles going so deep.
Thank you for your help in solving my problem.
I have the same exact problem!!!
Dear ‘Guest’
This is a very common problem. It always seems odd to me that many of those who care for AV fistulae seem unaware of the issues surrounding the depth of the fistula and the need - often driven by nurse needling difficulties, patient self-needling difficulties or pain into dialysis - for superficialisation.
In my own unit, fistula thrombosis is very uncommon, fistula stenosis is more common and superficialisation procedures the most common surical issue we encounter. Our surgeons … who, I must say, treat our AVF surgery as an art form and approach it with enthusiasm, skill and inventiveness … have no hesitation in superficialising the vein in order to give the needler (the nurse and/orthe patient … remember we have 30% of all our HD patients self-needling, at home, on home haemodialysis … the best angle and chance to insert a ‘painless’ needle.
Note, here, that ‘painless’ is in quotation marks … no needle - even buttons - are ever fully painless … but a needle shouldn’t hurt once its in - and if it does, there’s a reason … and if there’s a reason, that reason should be sought, understood, then corrected … and the reason for pain at the site after the needle is in and dialysis is underway is most commonly depth … the ‘digging up’ of the vein by a needle taped flat to the skin where the vein is deep and the needle is thus dragging on the vein as it pulls it closer to the surface.
It is a simple matter of ‘levers’ and ‘fulcrums’ … the sort of thing you will remember from science and maths classes in grade school … the point where the needle joins the hub being the fulcrum. As the needle hub outside is pressed down to be taped flat on the skin, the needle length inside … remember the needle is rigid steel … is forced to lever the vein up towards the surface. The deeper the vein, the greater the force … and the more pain. So, the simple answer is to bring the vein, surgically, closer to the surface = ‘superficialisation’. Its pretty simple and easy to do.
I have dealt with this issue in depth in the earlier posts of this thread.
I believe that 'needled88’, who raised this topic some months back, found relief from superficialisation. It is easy to do and, almost always, can be done in such a way as to permit ongoing use of the fistula during the healing phase and thus preventing the need for a bridging IJ catheter. At least, that’s our experience and our approach. It would be good to hear from ‘needled88’ again … to see if he/she is still comfy now with his/her needling. Maybe Dori has a way of contacting ‘needled88’ to ask for a quick update.
See your surgeon. It’s my guess … remember though: I don’t know as I do not know your specific circumstances … that this may be your problem.
Hi…much trouble logging in again. My revised fistula is working really well with no hint of throbbing pain.I am amazed to be able to sit there for 3½ hours without any pain.The only pain now is a sore butt.