:( Fistula Placement

Hubby went to see surgeon for evaluation for fistula surgery and the surgeon’s opinion was not good news. He said there is only one very short, possible A/V location in his lower arm near the wrist. A/V appear to be straight and parallel for only about 4" to 6" and the vein is not very large and is branched in such a manner that it might never be useable. He gave odds of success at 15% to 25%. We discussed using other sites, and a graft, but hubby has not yet decided whether to try for what is usually the best alternative – natural fistula, which can last for many years – w/ such low odds of success. :frowning: Or whether to just go for the less satisfactory option of the artificial graft. The surgeon gave odds of needing minor repair of artificial grafts at 3 to 4 times a year and eventual replacement as a certainty. Or whether to try the upper arm. :?

One thing of note: the surgeon was not familiar w/ the buttonhole technique, but after I explained it, he said that it could possibly make a shorter A/V section more likely to be useable and last longer, that is if the initial “ripening” takes place.

Anyone else have experience w/ a short fistula and/or a small branched vein?

Well, what do the upper arm veins look like? My fistula and a lot of other people’s are in the upper arm. The vascular surgeon picked the spot, and that’s where the fistula is. I think most expert opinion would be that an upper arm fistula is far preferable over an artificial graft anywhere.

He was unable to find anything useable in the upperarm and said doppler ultrasound would have to be done to locate possible sites if hubby decides not to try the one in the lower arm.

I have a short fistula, had it since 1984 and 2 revisions on it and is still working great…I have 4 buttonholes on it…one inch apart from each…

>>I have a short fistula, had it since 1984 and 2 revisions on it and is still working great…I have 4 buttonholes on it…one inch apart from each…>>

Thanks, Gus. Gives me hope that this just may work for him!!

If the other options for a fistula are not good, there’s no reason not to go with the graft. They are a little more problem-prone than a fistula, but I know many people who have one. I don’t think I would worry too much about it if it’s necessary. Fistulas aren’t totally problem-free either, at least not always. A graft is still far better than a catheter. What is the surgeon’s actual recommendation?

How about in the upper leg area? I know a brave patient who chose to go in the leg area which did work well…

If you have a chance for a short working fistula go for it! Pray to GOD that it will work out well…and after you have it be sure to exercise it to mature it quickly…and if possible, if okay by Dr. take a baby asprin a day to help it from clotting…only after maybe 2 weeks of surgery…

What did the doctor do to evaluate your husband’s arm for a fistula? If the doctor didn’t do vein mapping, this approach has been very successful in finding vessels for fistulas when other approaches didn’t.

The kidney community is focused on improving the number of fistulas in use in the U.S. because fistulas have the best outcomes so far as lasting the longest and the lowest rate of infection, clotting need for revision or replacement, hospitalizations, etc. They are so focused on this that the government has launched the Fistula First Initiative (see http://www.fistulafirst.org/). This website is targeted to professionals, but it might give you ideas for questions to ask your doctor of things you could print and share. There are lots of tools and resources designed to help professionals do a better job of making sure that patients that can have fistulas get them.

Here’s a website for continuing medical education on fistula placement with presentations by doctors who have been very successful in placing fistulas in almost anyone - http://cme.ouhsc.edu/5e016webtropages.htm. If the surgeon hasn’t seen this, you let him/her know about it.

If he says he would have to use the doppler, that sounds as if he didn’t. Even after the vein mapping/doppler I was told my veins were too wimpy. I was initially told that even a vein transposition would be useless. On the day before my “graft” surgery, the surgeon decided he could do a vein transposition, but after the surgery he was fairly certain it would fail. I could feel the “buzz” and kept my hopes up. He was so certain it was bad he wanted to do a fistulagram after 2 months, I refused and asked for another doppler (I didn’t want to shut down the little remaining function I had with the dye). The doppler showed great flows. I now have a huge fistula, albiet with a pain in the you know what curve making finding places to stick hard, with 4 perfect buttonholes. So glad I didn’t get the graft!!

self home hemo 9/04

I have had my fistula (close to my wrist) since Feb and have been using it since August( slow pump speed 200-225ml/min on Nocturnal) It is straight for around 4 inches and then I can not use it well because it branches out with tributaries but so far it is going well and I am buttonholing!!
The upper part of the lower arm is building up though with use and I hope to move my venous buttonhole up a bit before long.

Hi y’all,

The Buttonhole Technique (http://www.homedialysis.org/v1/types/buttonhole.shtml) was first developed by Dr. Twardowski for exactly the sort of problem Lorell’s husband may be facing–a short fistula. http://www.homedialysis.org/v1/research/articles/20050422.shtml

Many–possibly even most vascular surgeons do not know about the buttonhole. So, the emphasis on “short” veins may be because this surgeon is thinking about traditional “ladder” type needle placements which require a longer fistula. With the buttonhole techniques, a few inches of useable fistula would be long enough for even a couple of pairs of buttonholes–which could be used for years, or even decades.

That’s true, but when a person has fistula surgery in anticipation of being on hemo, there’s no guarantee at that point about anything in terms of being able to do home hemodialysis or buttonholing. Fistulas (or, maybe it’s fistulae) don’t necessarily develop as expected, and there are so many variables involved in the whole thing. You know, people are hospitalized sometimes, etc., etc. You really need as good a fistula as you can get.

Hi y’all,

I agree, Pierre, but given the choice of a short fistula or a graft, I’d take the fistula every time and do what I could to insist on using the Buttonhole Technique. But that’s just me (and, for the record, I’m not a patient).

Forgot to mention earlier, if you’d like to read more about dialysis accesses you can read Module 8 on Kidney School at http://www.kidneyschool.org.

Here’s a list of root causes for low AV fistula access rates in the U.S. It includes factors related to the patient, nephrologist, dialysis facility, vascular surgeon, insurance/reimbursement, and other factors. It’s taken from the CMS (Medicare) quality improvement template for increasing AV fistulas in hemodialysis patients. Some can be corrected while others may not be able to be corrected. It makes for some interesting reading.

I’d avoid having a catheter even for a short time if at all possible. I’d recommend this not only because of the higher infection risk with a catheter but because placement of a catheter can affect where a future AV fistula or graft might be successfully placed.

Here’s an article about how one dialysis team worked to improve their fistula placement outcomes:

And more on Dr. Nguyen and his approach:

Thanks so very much for the replies and links – excellent info. :smiley: As usual the best info comes from a message board and the links provided there, and not the professionals we paid. :frowning: I can’t imagine what happens to patients who do not have internet access. :shock:

We try to remind professionals and patients that Internet access is available at libraries and we’ve been trying to encourage dialysis clinics to make Internet access available to patients. We tell dialysis clinic staff that when they’re replacing computers to put one of the ones they would normally pitch into their waiting room and hook it to the Internet. If the rest of the clinic has wired or wireless Internet, it wouldn’t be hard to do. This would give patients the opportunity to plan a trip or learn something new. Wouldn’t it be great if doctors’ offices and hospitals did something like this in their waiting areas too? You might suggest this to your doctor(s). Maybe this could start a ripple that will turn into a swell.

Excellent idea. 8) I will suggest it. :smiley:

Hi Lorell. Did the access surgeon order venous mapping of your husbands arm? The standard is for patients to have venous mapping before access placement so the surgeon has a “picture” of the veins and arteries before surgery. In addition, after the fistula is placed, it is recommended to have mapping completed again in the 6-8 week period post surgery to see if any stenosis (narrowing) is forming.

Many surgeons are placing fistulas without the mapping hoping the fistula will be a success, but they should obtain venous mapping before going to the operating room. Hope this information helps.

You just gave me more info than the nephrologist and the surgeon combined. :x :frowning: :?

The first surgeon, who was seen on referral from the nephrologist, did NOT do vein mapping. :shock: After visual inspection under the light of a bright lamp, said he would not map unless the first attempt failed. He gave chance of a useable fistula from the first surgery at the wrist at 15% to 25%, due to small veins and branching. He said to plan on at least 5 months for the fistula to mature due to small vein size, and that if necessary, he would try other locations after mapping, or maybe just put in a graft. :frowning: :roll:

After doing online research, a conversation w/ the clinic where my husband plans to train on the NxStage, and reading board posts, I began a search for another surgeon for a second opinion. It took a few days but I found a group of 8 cardiac/thoracic/vascular surgeons who are affiliated w/ a local Catholic hospital (where we have qualified previously for free care). The nephrologist’s office said a second opinion was a good idea only AFTER :x :frowning: I gave them the new surgeons contact info. and requested a referral.

At the direction of the new surgeon’s office, appointments for vein mapping, and the initial surgical consult, were made that same day. :smiley: He had the vein mapping done this week and the consult is 1/4/06.

BTW, the tech who did the vein mapping said she did not see any problems but that the radiologist and/or surgeon might see something she didn’t. My husband said she took many, many pictures of every inch of his arm so it sounds like she was very thorough. The surgeon had ordered mapping of both arms, but Hubby only had his non-dominant arm mapped. Might start us off on the wrong foot w/ the surgeon but I’m sure the hospital will appreciate the cost savings, and my husband is VERY resistant to having the access in his dominant arm. He wants to be able to write and work while he is doing dialysis.