Overview

This information is about a non-surgical procedure called a fistuloplasty to unblock an arteriovenous (AV) fistula.

If you have chronic kidney disease, you might need a treatment called haemodialysis. This is when we attach a tube to a needle in your arm. Blood passes along the tube into a dialysis machine. This machine cleans (filters) the blood before passing it back into the arm along another tube.

We need to create special access to your bloodstream if you have long-term haemodialysis. The best way for us to do this is to connect an artery with a vein to make a large, strong blood vessel. This is usually done in your wrist or upper arm and called an arteriovenous (AV) fistula.

An AV fistula helps to move blood into the dialysis machine and return it to the body during haemodialysis.

Sometimes, even when you are careful, your AV fistula can become infected, blocked or narrowed. If you have an infection, you will need antibiotics. If there is any blockage or narrowing in your AV fistula, you might need to have a fistuloplasty procedure.

The aim of this information is to help answer some of your questions about having a fistuloplasty. It explains:

• the benefits of the procedure
• the risks of the procedure
• what you can expect when you come to hospital
• what happens after the procedure

If you have any more questions or concerns, please contact the interventional radiology (IR) department.

About a fistuloplasty

An interventional radiologist (IR doctor) does the fistuloplasty procedure. They are a doctor who uses X-rays to diagnose and treat conditions.

The IR doctor uses a substance called a contrast agent that shows on X-rays to help find the blockage or narrowing in your AV fistula. They then treat the blockage by stretching the blood vessels with a special balloon.

You have the procedure under a local anaesthetic. This means that you are awake during the procedure but do not feel pain. We might offer you sedation medicines to help you relax.

Benefits of the procedure

Your AV fistula can age with time and cause problems, such as scarring or clots. These problems may mean that the AV fistula does not work so well and is less effective for haemodialysis. Clots can cause blood to flow at a slower rate or to block the AV fistula.

A fistuloplasty procedure can help to:

• restore blood flow at the recommended rate
• treat clots that are forming at an early stage
• make sure that your AV fistula continues to work well
• make sure that you get the amount of dialysis that you need

If a narrowing or blockage is left untreated, your AV fistula may stop working.

Risks of the procedure

A fistuloplasty is generally very safe but, as with any procedure, complications are possible. The risks are different for everyone. Your doctor explains the risks before you sign a consent form agreeing to have the procedure.

The most common risks are listed in this section.

Bruising

Bruising is common around the site where we put in the needle (the puncture site) and usually goes away in a few weeks. There is a small chance that the bruise might become large and uncomfortable, but this does not happen often.

Infection

If you have a large bruise, there is a risk of it getting infected. You might need antibiotic treatment or surgery, but this is very rare.

Circulation problems

The thin tube (catheter) or balloon used for treating the blockage can cause damage to the artery or AV fistula. For example:

• Debris in the artery wall can cause a narrowing or blockage of the artery. If debris is knocked off during the procedure, it can also cause blockages of other blood vessels.
• Stretching the AV fistula or vein can cause a small tear (perforation). This might need treatment with a covered stent (a metal tube that stays in the body) or surgery.

If it is not possible to repair the damage, there is a very small and rare risk of needing to remove (amputate) the limb.

In cases where we cannot repair the damage within the AV fistula, it might not work properly. We would then need to use a flexible plastic tube called a dialysis line instead and create a new AV fistula. 

A narrowing of a vein in your chest can cause problems with an AV fistula. This might need to be treated by stretching the vein. If there is an injury during this procedure, it can be very serious and even life-threatening. We talk to you in advance if you need this treatment.

Allergic reaction

Some people have an allergic reaction to the contrast agent that is used to make the blood vessels show on the X-ray pictures. This is usually a small (minor) reaction, such as a skin rash, and does not often need treatment. 

Sometimes, an allergic reaction can be more serious and needs to be treated with anti-inflammatory medicines called steroids.

Treatment not working

There is a small risk that the treatment might not work. If this happens, your doctor will talk to you about other surgical options.

Radiation risks 

During a fistuloplasty procedure, you are exposed to X-rays. They are a type of radiation called ionising radiation. This may cause cancer many years or decades after you are exposed to it.

You might have some skin redness after the procedure that feels like sunburn. We do not expect this to be permanent. The redness might be harder to notice on brown and black skin. 

Interventional radiology (IR) is when we use medical imaging guidance to do minimally invasive procedures. The amount (dose) of radiation from these procedures is generally low. More complex procedures might involve a medium (moderate) dose of radiation.

The IR doctor and radiographer (health professional who specialises in medical imaging) make sure that:

• your radiation dose is kept as low as possible
• the benefits of having X-rays during your procedure are greater than the radiation risks

Radiation and pregnancy

Radiation can be harmful for an unborn baby. If you are or think that you might be pregnant, it is important to tell a member of your medical team before the procedure. We cannot do any procedure that involves radiation if you are pregnant.
 
If you can become pregnant from sex, you need to use protection (contraception) from the first day of your period until your appointment. This means that you will not be pregnant when you have the procedure.

If the first day of your period has already passed, please contact the interventional radiology (IR) department. We can then give you another appointment within the first 10 days of your period. 

We ask you to sign a pregnancy declaration form before the procedure.

Other treatment options

The main other treatment option to a fistuloplasty is surgery to make a new AV fistula. However, it is worth preserving an AV fistula for as long as possible before creating a new one. This is because the AV fistula is often a preferred route to access your bloodstream for haemodialysis.

If you are having long-term haemodialysis, it is especially important to preserve an AV fistula for as long as possible. There are limited blood vessels in the body that are suitable to make fistulas.