ARTERIO VENOUS FISTULA

Arterio venous fistula can be defined as the process of establishing a communicating prosthetic loop(shunt) or a direct communication between an artery and

vein ( fistula)

Indications
1)arteriovenous fistula is performed for providing an easy access for venipuncture with a large bore needle for purposes of haemodialysis
2)several varieties of arteriovenous communication may be achieved employinga buried synthetic prosthesis , an arteriovenous fistula or an external

prosthesis

sites of fistula:
radio-cephalic
brachio-cephalic
patient preparation



1)position:
the patient is positioned in supine with non-dominnt forearm extending on hand table
a) other arm may extended on an armboard

2)anaesthesia:
local anaesthesia
3)skin preparation:
Begin at the proposed site of shunt on forearm & hand from fingertips to several inches above the elbow.

Draping :
A large cuffed sheet is draped over the table under the area. A folded towel is wrapped around the area is clipped. A drape sheet is draped under the arm

is clipped. A drape sheet covers the shoulder is clipped under the arm. Use of additional drape sheets can be used to complete draping .

Arteriovenous tray:
1. Mosquito artery clamp
2. Mosquito artery clamp 4” STRAIGHT
3. Mosquito artery clamp (curved)
4. Rake’s/ cat’s paw retractor
5. Skin hook
6. Hudson’s toothed forceps 6”
7. Hudson’s non toothed forceps 6”
8. dissecting toothed forceps 6”
9. dissecting non- toothed forceps 6”
10. needle holder 6”
11. sponge holder
12. BP handle
13. bull dog (small tip)
14. bull dog (long tip)
15. heparin injector (small tip)
16. debakey vascular disease (fine tip)
17. sharp scissors (tungsten tip)
18. scissors 6”
19. pott’s scissors 8”
20. needle holder 6”
21. vessel dilators
22. aneurysm needle
23. Watson chain
24. internal mammary forceps
25. self retaining retractor
26. sertenskey (brachial clamp)

miscellaneous things:

1. vessel loop
2. infant feeding tube 6fr
3. sterile blade 11fr and 5 fr
4. disposable syringe (for local and flush) 10ml
5. disposable syringe (for heparin)2ml
6. heparin 1ml diluted with NS
7. injection xylocaine 1%
8. injection heparin 1ml
9. injection ampicillin 500mg
10. diathermy pencil and cable
11. earth pad
suture material
1. mersilk/ free ties 3-0
2. prolene 6-0 / 7-0 (for artery and vein)
3. etilon 3-0,26cms (for skin)

procedure :
1. The local anaesthesia is injected over the area to be operated
2. The incision is made over the selected arterial and venous sites. Often (the radical artery and cephalic vein of the proximal forearm)
3. The vein and the artery are well separated with the help of mosquito clamps and debakey forceps, for ease during anastamosis.
4. The artery to be anastamosed is clamped with the help of bull dog clamps
5. The vein is clamped with the help of mosquito artery clamps
6. One end of the vein is then tied with the help of 3-0 free ties and cut with the help of sharp scissors in case of end to side anastamoses is done
7. The other end of the vein to be anastamosed with the artery is well dilated with the help vein dilators of increasing sizes.
8. In case of side anastamoses is done then the vein is clamped with the help of bulldog calmps and the incision is made on the lumen of the vein with

the blade of a 11 size blade.
9. Next an incision is made on the lumen of the artery with the help of a pointed 11 blade and the arteriotomy is increased with a pott’s scissor
10. The free end of the vein is the mobilized towards the incision on artery and sutured with the help of 7-0 prolene
11. The site to the anastamosed can be regularly washed with heprin diluted in normal saline at regular intervals to help in easy anastamoses
12. After anastamoses is completed the vein clamp is removed first, followed by the lower arterial clamp and last the upper arterial bull dog
13. Check for any bleeding at the site of anastamoses
14. In case of slight bleedings give mild pressure and wait for sometime
15. If bleeding does not subside, suturing at the site of bleeding may be required.
16. Check to see if the trill is felt.
17. The wound site is then given a wash with antibiotic solution and the skin is sutured with 3-0 etilon
18. After completion of the skin suturing, the wound is closed with a protective dressing.