As a hemodialysis patient with an AV fistula or AV graft, it’s possible that you may encounter problems at some point with your vascular access. To receive adequate dialysis, your AV fistula or AV graft must be working properly. If there is any indication that your access isn’t functioning as it should, your physician may first prescribe a fistulogram.
A fistulogram is a special x-ray procedure that identifies abnormalities in the blood flow through your dialysis access that may be interfering with your dialysis treatment. This minimally invasive x-ray procedure uses contrast (a dye) and can detect problems like clots or narrowing. The fistulogram reveals areas of narrowing, enlargement, or blockage within the veins and arteries of your AV fistula or graft. Depending on what your fistulograms shows, an additional procedure or intervention may be necessary to restore adequate blood flow through your access so you can continue to receive adequate hemodialysis treatments.
What should I expect during a fistulogram?
You’ll be brought into a procedure room and asked to lie on a table. The staff will connect you to a monitor to track your heart rate, blood pressure and oxygen level. A sterile drape will be placed covering you from your shoulders down to your feet.
Your access site will be cleansed and you may also be given medication in the opposite arm to your fistula or graft to help you relax during the procedure. Before inserting a catheter, medicine will be administered under the skin to numb the area in question of your fistula or graft.
Once your skin is numb, a small catheter will be inserted into your access. Contrast, an x-ray dye, will be injected through the catheter so that your doctor can see what’s happening in your access. These x-ray images will allow the doctor to determine what’s causing your dialysis access to be dysfunctional.
At the end of the procedure, the catheter is removed, and pressure is applied over the puncture site. You can expect to wait in a recovery area for approximately one to two hours. During this time, a nurse will monitor your condition and ensure that any bleeding has stopped. Afterwards, you will be able to go home or proceed to the dialysis clinic for treatment.
What can be seen on a fistulogram?
A fistulogram may reveal the following:
- Abnormal narrowing (stenosis)
- Abnormal enlargement (possibly Steal Syndrome)
- Blocked veins or arteries (an occlusion)
If stenosis is found, your doctor may perform angioplasty as an intervention. Angioplasty is a minimally invasive procedure used to widen the narrowed portion of your fistula or graft by inflating a small balloon-tipped catheter inside your access to stretch open the narrowed area. This will allow blood flowing through your access to return to normal.
If the fistulogram indicates that your blood vessels are too enlarged, your doctor may recommend the MILLER banding procedure. Enlarged veins result in an increased amount of blood flowing through your access. This can limit blood flowing to your forearm and hand of the arm containing the AV fistula or AV graft, which can cause problems. This procedure is done by adjusting the access back to the proper size to restore the right amount of blood flow. Your physician will use sutures that act as a band around the vein to adjust the size and blood flow. An angioplasty balloon is also placed inside the vein to adjust the size of the band with greater precision. This allows the vessel to return to its normal size so adequate blood flow can be restored.
If your blood vessels are blocked or clotted, your doctor may recommend thrombolysis or thrombectomy. Your doctor will determine which one is better for you depending on your individual situation. Thrombolysis is a minimally invasive procedure that uses medication to breakdown blood clots that are blocking your dialysis access. Your doctor will instill a clot dissolving drug through a catheter to the site of the occlusion to allow the medication to reach the blood clot directly.
Thrombectomy is the actual removal of the blood clot. Your doctor will use a catheter to gain access to the vein and remove the clot using a special medical device. Both procedures will result in removal of the blood clot so normal blood flow can be restored. In some cases, both procedures may be performed.
Benefits of a Fistulogram (i)
- X-ray images can often provide enough information to avoid more invasive procedures.
- X-rays usually don’t have any side effects.
- A fistulogram provides real-time images that may be evaluated immediately.
- Provides doctors with precise information to help develop the best treatment plan for you.
Risks of a Fistulogram
Fistulograms are very safe procedures but there are some risks and complications that may occur.
- On occasion, a small bruise can appear at the site of the needle puncture
- There is a risk of infection, but it’s very low.
If you suspect a problem with your access, contact your dialysis care team immediately so you can avoid missing any scheduled dialysis treatment. Azura Vascular Care physicians are vascular specialists who perform minimally invasive procedures to treat a dysfunctional dialysis access safely and effectively in an outpatient setting. Same day/next day appointments can be available so patients can avoid hospitalization and return to their regularly scheduled dialysis treatments quickly. To find the Azura center nearest you, visit our center directory.
Sources:
(i) https://www.radiologyinfo.org/en/pdf/fistulogram-sinogram.pdf
