Percutaneous endovascular forearm arteriovenous fistula creation for haemodialysis access

Chronic (long-term) haemodialysis is used to treat advanced chronic kidney disease in many people who have renal replacement therapy.

An arteriovenous fistula is considered the best type of vascular access for haemodialysis. The preferred way of creating such access is to surgically join an artery and vein together in the distal forearm (radiocephalic fistula). However, other anatomical sites may be used. Alternative surgical approaches for vascular access include arteriovenous grafts and placing tunnelled catheters into a large vein. A minimally invasive, percutaneous, endovascular procedure is another way of creating an arteriovenous fistula.

This procedure can be done using different systems, and is usually done in a day-case facility under local anaesthesia, with or without conscious sedation. Using ultrasound or fluoroscopic guidance, 2 small needles are inserted into an artery and a vein in the proximal forearm, that is, the radial, ulnar or brachial artery and adjacent vein. Thin, flexible, specially designed catheters are then advanced and positioned by guidewires in the chosen vessels. The catheters are aligned close to each other (using inbuilt magnets or mechanically, depending on the system). The arterial and venous walls are then fused side to side using heat and pressure, or a small burst of radiofrequency energy released from the catheters. This creates an arteriovenous fistula between the target vessels. The catheters are then removed. High-flow arterial blood passes through the vein and, with time, it arterialises. This allows needles to be inserted into the vein to provide vascular access during haemodialysis.

The exact technique may vary slightly depending on the device used.