Having a fistula created for dialysis
What is a fistula?
A fistula is an enlarged vein in which needles can be inserted for haemodialysis. To create this large vein, an artery is joined to a vein usually at the wrist or the elbow. Blood from the artery enters the vein and causes the vein to widen and the vein wall to strengthen. The operation is attended in the Operating Suite by a Vascular Surgeon.
Fistula created at the wrist or the elbow:
How long will I be in hospital?
The surgery is usually a day case, meaning you can go home the same day as the procedure. It will not be safe for you to drive, so you will need to have someone to pick you up and take you home after the procedure. You should also have someone stay with you that night in case you become unwell.
Where do I go and do I need to fast?
The Theatre Liaison Nurse will call you at home to and let you know the time to arrive and where to go. The nurse will also let you know what time to fast.
What type of anaesthetic will I have?
The Theatre Booking Nurse will call you at home and organise for you to see an Anaesthetist at the Pre-Assessment Clinic before the surgery. The surgery can be conducted under Local Anaesthetic or a Regional Block with medication to sedate you. The operation may also be attended under a General Anaesthetic.
Can I take my medications on the morning of surgery?
You should take all of your usual medications before the operation, including aspirin. Do not take any blood thinning medication on the morning of surgery other than Aspirin. If you have Diabetes, follow the instructions given to you by the Anaesthetist.
What should I do before the operation?
You will be provided with a tube of Chlorhexidine antiseptic wash to use the evening before surgery and again on the morning of surgery to help prevent infection.
If you are a smoker, it is important to stop smoking before the surgery to help prevent complications such as a chest or wound infection. There is advice and information brochures we can provide to help you.
What will happen after the operation?
The nurses in the Day Surgery Unit will give you an information brochure on what to expect and how to care for your fistula after surgery.
- The operation may not work: Research shows that around the world 1 in 3 fistula operations do not work. The fistula may develop a narrowing or become blocked. When a fistula blocks, further surgery is often required to unblock the fistula or to create a new one.
- Bleeding: Major blood loss can occur during or after the operation. This may require a blood transfusion or a return to the operating theatre to stop the bleeding.
- Infection: With all surgery, there is a risk of infection. If there are any signs of infection, such as; redness, discharge, pain, swelling or you feel unwell, see a doctor in the hospital Emergency Department immediately. Seeing a doctor from the Vascular Surgery or Renal team promptly, may help prevent complications from infection.
- Nerve injury: There are nerves in the area of the operation that may become damaged causing an area of numbness on the thumb or inside the elbow. This feeling is usually temporary.
- Steal syndrome: This is where too much blood goes into the fistula and not enough blood goes to the hand causing a cool or cold hand with numbness. Less than 5 in 100 patients will require further surgery to improve the blood flow to the hand or to close the fistula.
- Aneurysm: Because of the high flow and pressure in the fistula, the wall of the fistula could weaken over time giving rise to a stretched section of the fistula. A small percentage of patients may require an operation to repair the aneurysm.
An ultrasound is attended to check the size and condition of your arteries and veins in your arms. This is called a “mapping” ultrasound. The ultrasound report gives the Surgeon important information to help plan where your fistula will go.
The time the fistula takes to develop to be suitable for dialysis varies and delays may be more likely if you are:
- have diabetes,
- older age;
- obese or have small veins.
For 6 in 10 patients the fistula develops within 12 weeks; for 2-3 in 10 patients longer than 12 weeks is needed and for 1 in 10 patients, the fistula never develops to be suitable for dialysis and another operation may be required.
You will be given an appointment to see the Vascular Surgeon. At this appointment, the surgeon will look at the veins in your arms and the report from your ultrasound. The Surgeon will talk to you about where the best place for the fistula would be and what to expect including the risks from the operation. Sometimes the surgeon writes a letter to the Nephrologist before making a decision.
Please tell the surgeon if:
- You have diabetes.
- You are taking blood thinning medications: Warfarin; Clopidogrel (Plavix) or Xarelto (Rivaroxaban). These drugs may need to be stopped before the operation.
Which arm can be used for blood taking after the appointment?
Continue to protect the veins on the arm to be operated on from any needles.