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AV Fistulas (AVF) –

these are native vessel connections

General consensus is that these are preferred over grafts but 65% of patients are not surgical candidates… Their veins are too small, atherosclerosis,or central venous occlusion.

  • AVG DURABILITY = 3 years, intervention extends up to 7 years.
  • Signs of fistula failure = arm swelling, elevated central venous pressure at dialysis, decreased thrill
  • SITES
    • Forearm = Radiocephalic (Brescia-Cemino) – 70%
    • Elbow/Arm = Brachiocephalic or brachiobasilic – 30%
  • BENEFITS
    • Better long-term patency
    • Lower rate of thrombosis o Lower rate of infection
  • PROBLEMS
    • Fistula takes, on average, 10 weeks to reach maturation for use.
    • Stenosis of the outflow vein (just beyond the anastomosis) B A Radiocephalic AVF with minor stenosis at anastomosis
  • (A) and major stenosis 2 cm into the outflow vein (B). AV Grafts

(AVG) – these are artificial conduits  Most common graft is a 6-mm PTFE (synthetic) graft

 AVG DURABILITY = 1-2 years

 intervention extends up to 3-5 years

 SITES o Upper extremity: Brachiobasilic, Radiocephliac, Axillary-axillary, Axillary-contralateral axillary (“necklace”), etc. o Lower extremity: Femoral-saphenous, femoral-femoral

 BENEFITS o Ready for use sooner, in 4-6 weeks o Can be placed in any number of locations

 PROBLEMS o **Stenosis at the venous anastomosis – 90% of cases secondary to intimal hyperplasia. o Less common stenosis occur inside the graft and in the outflow vein. o Thrombosis – o Infection – this is a contraindication to endovascular intervention.

 Treatment of graft thrombosis generally involves placing an angiocath and slowly infusing 2 mg tPA and waiting. There are also mechanical methods of thrombectomy.

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