Fistuloplasty and AV fistula repair: protecting your dialysis access without surgery

What can go wrong with a fistula

An arteriovenous (AV) fistula joins an artery to a vein, usually in the arm, so the vein becomes strong enough for dialysis needles. With time, narrowings (stenoses) form, often near the join or in the draining veins. Warning signs include prolonged bleeding after the needles come out, a fistula that feels weaker or has lost its thrill, high pressures or poor flow on dialysis, swelling of the arm, repeated clotting of the needles, and a fistula that has stopped working.

How the problem is found

Your nephrologist or dialysis team may notice falling flow, rising pressures or poor clearance. A Doppler ultrasound looks at the fistula and the narrowing. A fistulogram, an X-ray study with contrast dye injected through a small needle, outlines the whole fistula and the veins draining it, and is usually followed straight away by treatment if a narrowing is found.

How fistuloplasty is done

Fistuloplasty usually takes 30 to 60 minutes.

• The skin over the fistula is numbed. A small needle or sheath enters the fistula, usually where the dialysis needles go.
• Contrast dye shows the narrowing under X-ray.
• A guidewire crosses the narrowing and a balloon catheter is inflated across it, often with high pressure, to open it. A drug-coated balloon or stent graft may be used in selected cases.
• Dye is injected again to check the result. The sheath is removed and pressure is held on the puncture.
• After a short observation you go home, with advice on when to dialyse next, which is often the usual session.

A clotted fistula

If the fistula has clotted, the clot can often be removed through the same kind of puncture, using a catheter device, clot-dissolving medicine or aspiration, followed by balloon treatment of the underlying narrowing. The sooner this is done, the better the chance of saving the fistula, and delay can mean a temporary dialysis catheter. Contact your dialysis unit and the clinic immediately if the fistula stops working.

What the trials show

Standard balloon angioplasty is the usual treatment, but narrowings often return. In the IN.PACT AV Access trial of 330 patients with narrowings in native arm fistulas, a drug-coated balloon kept the target lesion open at 6 months in 82.2% against 59.5% with a standard balloon, with similar early safety ^[1]. For failing grafts (artificial tubes used instead of a vein), a stent graft was compared with balloon angioplasty in 190 patients, and treatment-area patency at 6 months was 51% against 23% ^[3]. Your doctor chooses the device from the scan and how often your fistula has narrowed.

Protecting your fistula afterwards

Fistuloplasty buys time, and good habits help it last.

• Never miss dialysis, and tell your team at once if the thrill or flow changes.
• No blood pressure cuffs, blood draws or tight clothes on the fistula arm.
• Check the thrill every day, and avoid sleeping on the arm.
• Keep your appointments for ultrasound or fistulogram, since narrowings can come back and are easier to treat early ^[2].

Risks and when surgery is needed

Risks include bruising or bleeding at the puncture, a tear or rupture of the vein (usually controlled with the balloon or a stent), reaction to contrast dye, and the fistula clotting. Some fistulas, such as those with a long or repeated narrowing, or large aneurysmal segments, need a surgical revision or a new access, and your vascular access team decides this together.

Cost and insurance

Health insurance can cover these procedures, subject to your policy terms. The exact cost is calculated after consultation, a complete evaluation of the problem, and a decision on the procedure that suits you. Cashless treatment can be arranged with major Indian health insurers and TPAs, and credit treatment is available for CGHS and Singareni beneficiaries. Eligibility is confirmed after a policy check.