Right Arm Fistuloplasty

Right Arm Fistuloplasty

A Fistuloplasty is a minimally invasive endovascular procedure used to treat stenosis or narrowing within an arteriovenous (AV) fistula, commonly used for dialysis access. It is performed using balloon angioplasty to restore optimal blood flow.

Relevant Anatomy

AV fistulas are usually formed between the radial artery and cephalic vein in the forearm. The brachial artery, basilic vein, and subclavian vein may also be involved in variations. The anatomy of the venous outflow is crucial for guiding catheter and balloon positioning.

1. Instruments and Equipment Checklist

Endovascular Tray (Sterile)

• Scalpel blade (No. 11)
• Sterile drapes and towels
• Syringes and needles (5 mL, 10 mL, 20 mL)
• Wire introducer set (0.018" and 0.035")
• Sheath introducers (4Fr to 6Fr)
• Guidewires (e.g., hydrophilic, stiff, angled tip)
• Balloon catheters (e.g., 5 mm to 8 mm diameter)
• Angiographic catheters (e.g., Cobra, pigtail)
• Hemostatic valves and Y-connectors
• Sterile ultrasound probe cover (if using US)

Imaging & Radiology Equipment

• C-arm fluoroscopy unit
• Radiopaque contrast media (e.g., Omnipaque)
• Lead aprons and thyroid shields
• Digital subtraction angiography (DSA) capability

Sutures

• 4-0 Nylon or Steri-Strips for puncture site closure

Other Equipment

• Pressure bags and IV fluids
• Manual compression materials or closure devices
• Sterile ultrasound probe (for vascular access)
• Flush solution (heparinized saline)
• Local anaesthetic (lignocaine 1–2%)

Fluids and Medications

• Heparin: IV bolus to prevent thrombus formation
• Local anaesthetic: Lignocaine 1% subcutaneous
• Contrast media: Omnipaque or Iohexol for imaging
• Saline: For flushing and catheter patency

2. Before Knife to Skin

1. Verify laterality and site of fistula (right arm)
2. Ensure imaging equipment is functional and C-arm aligned
3. Check contrast media availability and compatibility (renal function/allergy)
4. Initial count of swabs, sharps, and wires
5. Sterile draping around arm and imaging field

Prepping and Draping

• Prep entire arm using alcoholic chlorhexidine
• Drape using angiography arm board and sterile sheets
• Ensure lead protection for team and sterile C-arm covers

3. Intraoperative Stages

1. Access: Puncture the fistula vein under ultrasound or palpation guidance; insert sheath
2. Angiography: Inject contrast via catheter; fluoroscopy used to visualize narrowing or occlusion
3. Balloon Angioplasty: Advance balloon catheter to stenosis site, inflate under fluoroscopy to dilate narrowed segment
4. Post-Dilation Imaging: Recheck flow using contrast; confirm patency
5. Closure: Remove sheath and achieve hemostasis with pressure or closure device

Radiology in Fistuloplasty

Radiology is critical during fistuloplasty. Fluoroscopy and contrast angiography are used to:

• Identify stenosis, thrombosis, or aneurysmal changes
• Guide wire and balloon placement accurately
• Confirm successful dilation and improved flow post-procedure

Digital subtraction angiography (DSA) enhances vascular clarity by removing bony and soft tissue background in real-time.

Common Intraoperative Challenges

• Inability to cross stenosis with wire
• Balloon rupture or failure to fully dilate lesion
• Vessel rupture or dissection
• Thrombosis or embolisation
• Allergic reaction to contrast media

4. Post-Op Tasks

• Monitor puncture site for bleeding or hematoma
• Check distal pulses and capillary refill
• Document type and size of balloon used, volume of contrast
• Clean and dispose of wires and sharps appropriately
• Update vascular access team and dialysis notes