Shoulder surgery with fistula

Hi Dr. Agar,
I’ve been putting off surgery for an injured right shoulder for as long as I can. It’s only a matter of time before I’ll need surgery. I am concerned about surgery so close to my fistula and all the vascular changes that have been made. I also wonder about being able to position and cannulate that arm during the recovery period after surgery. I dialyze at home while I sleep.

I’ve met with two shoulder surgeons. Each has given me a shot of cortisone which is temporary as you know. At the time I didn’t ask them about the surgery specifically but when they saw my fistula I sensed they were (understandably) uncomfortable with the idea of surgery. It’s time for me to talk to them directly about the surgery with a fistula. This injury is preventing me from enjoying many of the activities I like for myself and my son.

Do you have any knowledge about this situation? Thank you for your input or direction.

Wendy Ramsay

Dear Wendy

Thank you for your question. It is one, though, that can only be correctly answered by knowing the details, both of your AVF and its history and of the intended shoulder surgery you are likely to have.

That said, there are some general points I could make.

  1. Before starting, your orthopaedic surgeon should talk directly with your nephrologist and your vascular surgeon. Communication and understanding at a clinical level regarding the course your AVF veins take through the shoulder region, the anatomy of any disturbance to the vasculature in your shoulder that may have resulted from the maturation and presence of your AVF, and the risks (if any) of blood vessel division or compression in or around the shoulder that may result from orthopaedic surgery by an unaware orthopaedic surgeon … all are vital to inadvertent risk-protective surgery.

  2. That said, there is then no reason why shoulder surgery should be a problem if done carefully and with knowledge a-forehand.

  3. Surgery from the posterior (behind the shoulder) approach is likely to be the least risky. However, depending on the nature of your shoulder problem - this I do not know - the approach may need to be anterior (as it is for most shoulder surgery).

Your orthopod needs to be aware not to put constrictive pressure on the vessels anterior to the shoulder … this is where the normal vessels that drain your AVF run.

However, if you have had any central stenotic problems … a narrowing of the great veins within the chest (the axillary vein, the superior vena cava or, if the fistula is (L) sided, the (L) inomminate vein) which may have resulted from prior central catheters etc., then there is the possibility of a pre-formed ‘collateral circulation’ to drain the AVF – and this, in turn, may have led to alternate vein drainage pathways posterior to the shoulder.

If the central veins are restricted – say, by a stenosis (narrowing) resulting from scaring as may occur commonly after an internal jugular catheter has been in place for any length of time - the AVF may drain through veins other than those that normally drain the arm. This is called a ‘collateral circulation’. As an example, ‘collateral channels’ often form if a river is blocked: the water dams up behind the blockage until new drainage routes are found to relieve the back pressure. Ultimately, a whole new river course – or set of courses – are found so that the river can continue its’ onward flow.

The same happens if a vein is obstructed … ‘collaterals’ form – and they can form in unexpected places. This may not be applicable to you … but this is the kind of information your nephrologist or vascular surgeon can provide to the orthopaedic team and which I do not have … and knowing is 9/10ths of the avoidance of trouble. If there is doubt, it may be easiest to do a fistulogram to plot the course of the vessels - but this may only be worth doing if there is uncertainty. Your nephrologist or vascular surgeon will know this and be able to easily make a decision if this additional step is warranted.

  1. Surgery from the front of the shoulder is (or may be) a little more tricky … though this , of course, will depend on what surgery is to be done in the first place. The type of surgery, the dimension and position of the intended surgical approach, these and other details are not known to me but will be to your orthopaedic surgeon and can be discussed with your dialysis team and vascular surgeon to ensure no misadventure results. Its a simple phone call. Make sure it is made.

All that said, yours is not an uncommon situation. It is not likely to be a huge or significant risk to you or to your AVF or to the ongoing and immediate use of the AVF for dialysis after surgery – though some modifications to your anticoagulant regimen may be needed for a little while.

Communication, communication and more communication are the keys. That assured, then little might be expected to then go wrong. Of course, no surgery is without some risk. What is important is that that risk is minimised.

It sounds like your shoulder has come to a key point where it is restricting your lifestyle - either by physical restriction or through pain. If so, I’d get it fixed, if it can be.

Thank you, Dr. Agar for your very thorough reply! It is good to know that this is doable and that it’s not an uncommon situation. I will be certain that everyone involved is communicating. I agree on how important that is. I am sure I’ll read your reply several more times in order to understand everything and in order to discuss the points in your reply with my doctors. It’s only a matter of time before I can no longer put it off. Plus, as I am in the process to be cleared for transplant, it may be something I should have done before transplant. But then again, maybe it would be more convenient to do after (whenever that will be).

Thank you again! I found this very helpful.