Who is this leaflet for? What is a fistula? How is the fistula formed?

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1 Your fistula

2 Who is this leaflet for? Your doctor has told you that your kidneys are not working properly. One of the many functions of the kidneys is to get rid of waste products from your body. If your kidneys fail, these waste products build up in your system. Having discussed the treatment options available with your consultant and pre-dialysis nurse specialist, you may have opted for haemodialysis. Before you start dialysis, it is important that you are well prepared. Your consultant will refer you to a surgeon to discuss forming a fistula. This leaflet explains this procedure, including what to expect and the risks and benefits. These are general guidelines for your information and may not apply to specific cases. What is a fistula? A fistula is a passage between your blood vessels, which is formed surgically. It provides the necessary access to your bloodstream to allow your blood to be cleaned by the dialysis machine. How is the fistula formed? In a small operation on your arm, your artery (the blood vessel that carries blood away from your heart) is joined to your vein (the blood vessel that carries blood back to your heart). This increases the blood flow through your vein and the vein becomes enlarged. No foreign body or plastic material is inserted into your arm, and nothing sticks out of your skin after the operation. Fistula Vein Artery 1

3 Why do I need a fistula? When you have haemodialysis, two needles are inserted into your vein. The veins in our arms are small and have thin walls. By creating a fistula, the vein enlarges and develops a thicker wall. This makes inserting the dialysis needles easier and also provides enough blood flow to help remove the toxins and waste products from your blood. A good fistula will allow safe, reliable, repeated access to your circulation for haemodialysis. What are the benefits of having a fistula? Dialysing through a fistula will provide a much better blood flow rate, and therefore better dialysis, than a neck line (a line inserted into your neck vein). Having a fistula also means that you should not need a dialysis neck line, therefore reducing the risk of developing septicaemia (blood infection). You should have fewer hospital admissions for access-related problems and therefore more time to do what you enjoy doing. You can also go swimming and have a shower with a fistula. Having a successful fistula is the most important factor for enhanced quality of life when you are on dialysis. Success is not guaranteed, but there can be more than one attempt to create a fistula. The alternatives have a much higher complication rate and do not last as long. What are the alternatives? A neckline or haemodialysis catheter. However, the risk of infection is 20 times higher than having a fistula. The time spent on dialysis is usually longer, as greater flows are achieved via a fistula. In time the catheter will damage the vessel wall, and you will need to have it removed. The life span of a line is around one year, whereas one fistula can last over 20 years if necessary. All of this means that with a line you are 10 times more likely to be admitted to hospital. You also need to keep catheters clean and dry and to ensure there is a dressing over the catheter at all times; water sports are out of the question. Where are fistulas located? The most common areas are at the wrist and the elbow. In these sites the artery is close to the vein, and the vein runs close to the surface of your skin. The wrist fistula dilates the vein in your forearm. The elbow fistula dilates the vein in your upper arm. 2

4 How quickly can the fistula be used? A fistula cannot be used immediately. We need to wait for the wound to heal, any bruising and swelling to go down, and for the fistula to mature. After the operation, the blood in your vein is under higher pressure. This causes your vein to expand and the wall to strengthen. The fistula can only be used when the wall is strong enough to take the needling for dialysis. This usually takes around three months. Why should I have a fistula created now? It is important that your fistula is ready before you need to start dialysis. It is better to create a fistula early rather than too late. This gives time for your vein to enlarge and mature so that your fistula is ready for the dialysis. Fistula Vein Artery How is the fistula used for dialysis? A local anaesthetic is applied to the area and then two needles are inserted into the enlarged vein. The needles are secured with tape. One needle is inserted into the lower part of the fistula and takes blood from your body. The blood is pumped through the dialysis machine then back to your body via the top needle. After dialysis the needles are removed and the puncture sites are covered with a plaster or dressing. 3

5 What is the success rate? About 50% for the forearm fistula and 70% for the upper arm fistula. This is the overall average; there are many reasons for failure. The more damage done to the arteries and veins before the fistula operation, the lower the chance of success. It is vital that your proposed fistula arm is kept in the best possible condition. Do not allow anybody to stick a needle or cannula in any vein in your proposed fistula arm. Can I choose which arm is used? You may indicate which arm you would prefer your fistula to be created in. If the surgeon considers the vessels in that arm are adequate, they will usually follow your request. If the surgeon considers the vessels on the other arm are more likely to result in a successful procedure, this will be explained to you. The usual procedure is a wrist fistula first, unless there are specific circumstances. What happens before my operation? The vascular surgeons have the skills necessary to perform fistula operations. Often they will see you before the day of your operation, unless they feel it is very straightforward. They may request special tests to look at your blood vessels more closely to help them choose the best option for you. This may be with dye study or an ultrasound probe. What happens during my operation? On the day of your operation you will be admitted to a surgical bed at the Royal Cornwall Hospital. The fistula operation usually takes less than an hour, and can be done under local or general anaesthetic. The surgeon and anaesthetist will discuss this with you at the time of your admission. Most people are not distressed by either approach; a few actually choose to watch the operation taking place under local anaesthetic. Your surgeon will usually first create a wrist fistula. If this fails, they will try to create an elbow fistula. However, if the first attempt is an elbow fistula and it fails, then the vein has been damaged and the wrist fistula on that side cannot be tried. If all the traditional sites have been exhausted, there are other opportunities for fistulae, and these will be explained to you if necessary. 4

6 The ward, the time to come in, the duration of your stay, the type of anaesthetic and the need to alter your medication will be individually arranged depending on you, the surgeon and the planned fistula. What happens afterwards? You will be left with a scar, about 5cms long, and hopefully a fistula. Your stitches will need removing after 7-10 days, unless they are dissolvable. This will be explained to you. In the first few days your fistula is weak and highly vulnerable. Make sure you follow the guidelines below to care for your fistula. In time you will see your vein getting bigger and you will feel a buzzing. As your fistula gets stronger, the buzzing will increase and the vessel will expand. Squeezing a ball to exercise your hand may help to develop the fistula. We will monitor its development; the first use of the fistula will depend on how it develops and when you need to start dialysis. Will I be able to use my arm after the operation? It will be sore for a week or so, which will limit your use a bit. Keep the wound dry until the stitches are removed. Otherwise, your arm should be fully functional. How do I care for my fistula? It is important that you take great care of your fistula at all times. keep it warm do not wear a watch or bracelet if you have a wrist fistula do not squash it or wear tight clothing around it never carry your handbag around your arm make sure you drink your daily fluid allowance; dehydration can affect the flow of blood through the fistula use the exercise ball you have been given monitor it and report any changes day or night 5

7 never let anyone take blood from it use your other arm for blood pressure measurements. How do I check my fistula? Caring for your fistula arm must become part of your daily life. You will be shown how to check your fistula for a buzz. Every day, you will need to check your fistula is working by feeling for this buzz. If you cannot feel this at any time, contact the Renal Unit immediately. Are there any risks? There are no life-threatening risks associated with having a fistula formed. However you should be aware of the possible complications: Blood clots can form at the operation site. This may occur as a result of sustained drop in blood pressure, dehydration or for no apparent reason. A haematoma (bruising) may develop at the site of the operation, which will usually resolve itself without the need for a further procedure. Steal syndrome may occur as a result of your blood being diverted from your hand to your fistula. The major symptoms are pain and skin discolouration. This rarely occurs but if it does, your surgeon may suggest a second operation to modify the fistula. There are always nerves around the site of a fistula operation. These nerves are often bruised during surgery, leading to tingling in the fingers and thumb, which may last as long as three months. There is always a risk that the nerve may be cut. The chances of this are very, very small, but could lead to irreversible numbness over the area the cut nerve supplied. Infection, should it occur, can be treated with antibiotics. A message from the team We are here to help. Your fistula is your lifeline; when your kidney stops working adequately, you will become dependent on dialysis. Facing kidney disease and life on dialysis can be a frightening and overwhelming prospect, but education and information are key to making the most of this new life situation. You will need to learn to eat the right food, stick to your fluid allowance, take the correct medication and to exercise in the appropriate manner. 6

8 While you have ultimate responsibility for your life, other people are available to support you. These include doctors, the chronic kidney disease clinical nurse specialist, the dietician, the anaemia nurse specialist and the specialist practitioner. Contact us If you have any queries or need any further information please contact: Geraldine Hyslop, Chronic Kidney Disease Clinical Nurse Specialist Dialysis Unit (7am 10pm) Grenville Ward (other times) Further support and information is available from: If you would like this leaflet in large print, braille, audio version or in another language, please contact the Patient Advice and Liaison Service (PALS) on RCHT 932 RCHT Design & Publications 2006 Revised 10/2015 V3 Review due 10/2018