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Fistuloplasty

Preparing for Blood Test

A fistuloplasty is a minimally invasive procedure performed primarily in the realm of interventional radiology or vascular surgery to address stenosis or occlusion within a fistula, typically an arteriovenous fistula (AVF) or arteriovenous graft (AVG). This intervention involves the introduction of a catheter into the affected blood vessel, often guided by fluoroscopy or ultrasound imaging, followed by the deployment of a balloon catheter at the site of the stenosis. Upon inflation, the balloon dilates the narrowed or obstructed area, thereby improving blood flow through the fistula or graft.

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Fistuloplasty involves the percutaneous transluminal dilation of a vascular fistula or graft, aiming to alleviate stenosis or occlusion. This could be in the arterial an/or venous segment of the fistula.
It encompasses the advancement of a specialized catheter, usually under fluoroscopic or ultrasonic guidance, to the site of stenosis within the vascular fistula or graft.
Utilizing a balloon catheter, the stenotic segment is dilated by controlled inflation, permitting restoration of blood flow dynamics through the affected vessel. Current practice is moving towards intervention with drug-coated balloon angioplasty (fistuloplasty) to prolong the reoccurence of restenosis.
Angioplasty with or without stenting is indicated when there is significant stenosis or occlusion impeding adequate blood flow through the fistula or graft, which is crucial for hemodialysis in patients with end-stage renal disease (ESRD).

A&I Protocol

Fistulogram (Fistuloplasty +/- Stenting) Preparation and Exam:​

  • Patient is lying supine on the angiography table with their affecred arm with AV fistula  supported on a sponge and arm board.

  • The radiographer positions the C-arm in the head position and the detector in landscape.

  • Sterile preparation of the arm.

  • Seldinger technique is used to access the artery or vein under ultrasound guidance.

  • Under fluoroscopy guidance, the fistula is within the FOV and fistulograms are performed from the arm and up towards the shoulder and lastly in the thorax (to check for any central vein stenosis).

  • A wire is used to access the the fistula, and measurements are performed by the radiographer if any stenosis is seen. Diameter and lengths required.

  • The physician uses a balloon and dilator to perform the fistuloplasty (either using a plain balloon or a drug-coated balloon).

  • A post-dilatation fistulogram is performed. If the stenosis is resistant to the fistuloplasty, then a stent can be deployed.

  • A post-stent and dilatation fistulogram is then performed.

  • Following treatment, the access is removed and the physician usually stitches the access site and applies manual pressure.

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Left arm fistulogram demonstrating in-stent stenosis.

Angiogram showing post-drug coated balloon angioplasty.

References

  1. Karunanithy N, Mesa IR, Dorling A, Calder F, Katsanos K, Semik V, et al. Paclitaxel-coated balloon fistuloplasty versus plain balloon fistuloplasty only to preserve the patency of arteriovenous fistulae used for haemodialysis (PAVE): study protocol for a randomised controlled trial. Trials. 2016 May 12;17(1):241.

  2. Karmota AG. Paclitaxel coated-balloon (PCB) versus standard plain old balloon (POB) fistuloplasty for failing dialysis access. Ann R Coll Surg Engl. 2020 Oct;102(8):601–5.

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