Renal Fistula / AV Graft

 The autogenous AV fistula is the current procedure of choice for patients requiring permanent hemodialysis access. Blood flow in the autogenous AV fistula increases with time, and the resulting vein wall thickening prevents venous tears and infiltration during dialysis. The standard AV fistula is usually constructed by anastomosing the cephalic vein to the radial artery at the wrist level. Access can also be built in the upper arm as a straight communication between the brachial artery above the elbow and the basilic or axillary vein. A Doppler flow probe may be used.

AV Fistulas

Connection of artery to superficial vein

Lowest complication rate

Long-lasting

Require 6-12 weeks for maturation

• Avoid BP or sticks on the chosen arm

AV Grafts

A graft made of synthetic material connects the artery and a large, deep vein.

Can be used 2-4 weeks post surgery

Shorter life than fistulas

• Prone to infection, may require declotting

Anesthetic Considerations:

Consider interscalene block

• Note coagulation status if on dialysis

The patient still needs pain medication during the procedure

Keep BP within 20% of baseline to ensure graft perfusion - some use pressors, some fluids

Antibiotics with graft placement

• Cefazolin 1 g

Respiratory

Pulmonary edema due to fluid overload

Hemodialysis contributes to hypoxemia due to V/Q mismatch and hypoventilation

Cardiac

HTN related to fluid overload

Renal

Access weights and thus the effect of dialysis

Note K⁺-level if using succinylcholine

Hematologic

Chronic anemia due to bone marrow depression, lack of erythropoietin, nutritional deficiency, and diminished red-cell survival

Patients adjust via increased CO₂ and increased 2,3-DPG

• The right shift in the oxygen dissociation curve enables O₂ unloading

GI

NV, anorexia, decreased gastric emptying

• Consider premedication with Reglan and Ranitidine

Neuro

Neuropathies

Pain with tunneling of graft