1. Haemodialysis Fistula Intervention Dr Ralph Jackson Freeman Hospital Newcastle-upon-Tyne

2. What are Arterio-Venous fistulae? Surgically created “end to side” shunts which allow dialysis. Lower arm (radio-cephalic) better than upper arm (brachio-cephalic, brachio- basilic, brachio-brachial). Native better than grafts (PTFE, bovine ureter)

3. Anatomy

5. Typical AV Fistula “Arterial” needle “Venous” needle Thrill

6. Typical AV Fistula Arterial pressure Venous pressure

7. Problems with fistulae Poor development Difficulty needling Inadequate dialysis –Low flow rates –Recirculation High pressures and prolonged bleeding Thrombosis Almost all due to stenoses which are recurrent

8. Flat AV Fistula: peri-anastomotic stenosis “Arterial” needle “Venous” needle Weak thrill

9. Pulsatile AV Fistula: stenosis away from anastomosis Flat Remote Thrill Pulsatile and high pressure

10. Recirculation “Arterial” needle “Venous” needle Thrill

11. Treatment options Angioplasty –Standard balloon angioplasty –High pressure balloon –Cutting or scoring balloon Surgery Refashion anastomosis Patch stenosis Higher fistula Whichever way, get on with it.

12. Balloon angioplasty Big enough –Tendency to use too small balloons High or ultra high pressure –Standard RBP of 15Atm @8mm Inflation handle (obviously). Long inflation times as recoil common. Rupture uncommon but be prepared

13. Antegrade transvenous

15. Retrograde transvenous

16. Transarterial

17. Standard pressure balloon

18. High Pressure

19. Cephalic arch stenosis Much commoner in dysfunctional brachio- than radio-cephalic fistulae (~50%). More prone to rupture and restenosis Primary patency rates at one year after angioplasty only around 30%

21. Rupture management Not that frequent to have major rupture (1- 2%). Tamponade with long low pressure inflation Covered stent as bail out Associated with subsequent loss of fistula

22. Balloon Tamponade

23. Covered stent/stent graft

28. Conclusion AV fistulas are simple to understand. – History and examination are diagnostic. Most problems are due to stenosis. Angioplasty is highly successful if done right. Stenoses recur so you will get to know the patients well. Maintaining dialysis access is one of the most important IR jobs.