Vascular Surgeon's Critical Role in AV Fistula Care

An AV Fistula (AVF) is a connection created between an artery and a vein to increase the blood flow in the vein so that it may be used for cannulation during dialysis .Commonly done at the elbow and the wrist.

As an esteemed member of Vascular Society of India who is celebrating Vascular Awareness Week from August 3-9. Today, I would like to focus on a crucial topic: AV Fistula awareness.

Let me recount a tragic story

A 45 year old labourer from rural karnataka underwent an AVF surgery in his left elbow for dialysis close to a year ago at a renowned government nephrology and urology institute. He suffered initially from pain in his left hand during exercise and dialysis that progressively increased to pain at rest that did not allow him to sleep to a stage where he has a black finger and a non healing wound. He has been managed with painkillers ,antibiotics and dressing with not a single doctor able to diagnose or evaluate him or refer him for an intervention . His dialysis technician in the end taking pity on him referred him to us where we evaluated and diagnosed him with ‘STEAL SYNDROME’ and corrected it with a surgical procedure . He now has no symptoms, his gangrene has been contained and his AV Fistula is still functioning . As members of the medical fraternity have we failed this patient ?

Is there a critical irreplaceable role for a Vascular and endovascular surgeon in the realm of AV access ? I would have to say the answer is a loud and resounding YES!

In a somewhat nebulous area -a surgical niche if I may call it so -Creating an AV access is often done by all and sundry , ranging from urologists, Cardiac surgeons ,general surgeons , transplant surgeons, nephrologists and even plastic surgeons. Everyone would like their fingers in the pie that is AV access. Since the limited understanding by most people is that AVF boils down to ‘AVF=ARTERIAL AND VEIN ANASTAMOSIS’.

Is there someone who can select the site for the AVF , image the veins themselves , plan an alternative conduit , check arterial velocities , plan an AV graft , tackle complications such as pseudoaneurysms, blow out , steal syndrome , diagnose and manage central venous stenosis – well all rolled into one is the description of a Vascular surgeon.

The knowledge and experience that comes with performing thousands of anastomosis fashioning different hoods in different configurations using a multitude of different graft materials is a skill that is unsurpassed that is unique to vascular surgeons .

Very often we encounter complications that could have easily have been prevented with proper site selection and pre operative imaging . Life threatening Venous hypertension due to AVF created on a site with existing central venous stenosis . Gangrene in multiple fingers leading to amputation due to undiagnosed and neglected steal syndrome .

Modern medicine is moving away from procedure based approach to a patient based approach and a vascular surgeon is able to take an informed decision about the anatomical factors patient factors and correct the offending complication if required . This saves multiple referrals to multiple specialists ,work days,multiple admissions and costs for the patient and their family .

Let's work together to spread awareness about AV Fistula care and the importance of seeking expert Vascular Surgeons for AV access management. For more information, consult a Vascular Surgeon or visit the Vascular Society of India website.