WHAT IS A FISTULA?

A fistula is a surgical connection between an artery and a vein. The fistula is created to provide enough blood flow at the appropriate pressure to make hemodialysis effective and possible.

WHAT IS A FISTULAGRAM?

A fistulagram is a x-ray study of your fistulas this procedure and can detect problems such as a clot or narrowing. Early detection and treatment can improve your fistula’s performance and limit future complications.

WHY DO I NEED A FISTULAGRAM?

You may be having symptoms that suggest a blockage of your fistula.

For example:

• A blockage in your fistula may cause high venous pressures during your dialysis.
• If you cannot feel a thrill with your fistula, the fistula may be completely blocked.

The blood vessels that are connected to the fistula are subjected to higher rates of blood flow and pressure. Often, this results in the formation of scar tissue, causing narrowing of the fistula or blood vessels. A fistulagram can identify exactly where the artery or vein is blocked, how severe the blockage is, and what is causing the blockage.

HOW DO I PREPARE FOR THE PROCEDURE?

If you are already a patient in the hospital, your doctors and nurses will provide you with instructions. If this will be done on an outpatient basis, please follow these listed instructions:

• No solid food within 6 hours of your scheduled appointment. You may drink clear liquids (such as apple, grape, cranberry juices, soda, water, and tea) up to 2 hours before the procedure.

• Notify our department as soon as possible at (434) 924-9401.

• If you take glucophage, insulin, or a blood thinner so that we can adjust your dosage.  Take your other medications as usual.

• Let us know if you have an allergy to x-ray (contrast) dye so that we can take the necessary precautions.

• Bring a list of all of your medications or your medication bottles with you on the day of the procedure.

• You will need someone to drive you home.

An Angio nurse will attempt to call you 1-2 days before your scheduled appointment to review these instructions, obtain important medical information, and answer questions and concerns that you may have.

WHAT HAPPENS BEFORE THE PROCEDURE?

1. A nurse and an Interventional Radiologist (a doctor specially trained to perform this procedure) will talk to you about the procedure in detail.  They will answer your questions and ask you to sign a consent form.
   
   
2. You will be asked to put on a hospital gown and remove anything metal (such as jewelry or false teeth/dentures).  If possible, you should leave your valuables and jewelry at home.
   
   
3. Your family or friend(s) will be asked to go to our designated waiting area.
   
   
4. An IV will be started to allow us to give you fluids and pain and sedation medications.
   
   
5. You may also need lab or blood tests done before the procedure

WHAT HAPPENS DURING THE PROCEDURE?

You will be taken into our procedure room where you will be place on the x-ray table.  Your blood pressure, heart rate, and oxygen level will be watched closely. Betadine (brown-colored iodine soap) will be used to wash your fistula site where the catheter will be inserted to reduce the chance of infection. Lidocaine or Xylocaine (a medication similar to what a dentist uses) will be injected to numb the skin.  It will sting and burn for a few seconds before the area becomes numb.  However, you will still feel some pressure.   A nurse will also be present to give you medications to help you relax and reduce your discomfort. Because you need to hold your breath while we take some x-ray pictures, you will need to be awake during the fistulagram.

The Interventional Radiologist will insert a needle into our fistula, very similar when accessing your graft for hemodialysis you will feel warm in your hand, arm, and chest, and may get a metallic taste in your mouth. These sensations only last 10-15 seconds.  Several x-ray pictures are needed to complete the test.These pictures are reviewed by the Interventional Radiologist and, if necessary, the findings discussed with your referring doctor.  If there is an area of narrowing or clot present in the blood vessel that can be helped by balloon angioplasty, stent, clot dissolving medications, or a clot breaking device, this may be done at this time.  A fistulagram usually takes 2-3 hours to complete.

Angioplasty is the inflation of a balloon inside the narrowed area of a blood vessel.  Usually, a second needle must be placed in another part of the fistula in order to perform angioplasty.   A plastic tube with a balloon attached is positioned at the level of narrowing. The balloon is inflated several times. You may feel pressure due to the stretching of the vessel. The goal is to make the vessel opening bigger and allow for better blood flow.

WHAT ARE THE RISKS OF A FISTULAGRAM?

With modern techniques, a fistulagram is a relatively safe procedure, however, the procedure is not totally risk free.

• Placing a catheter in your artery can damage it.  Even when it has not been damaged, you may have a bruise or small lump where the catheter was inserted.  The bruise or lump may be sore, but will go away in a few days.

• A few patients will become sick from the contrast dye.

• A member of the Interventional radiology team will discuss the exact risks of your fistulagram with you in detail before your procedure begins.

WHAT IS THE BENEFIT OF HAVING A FISTULAGRAM?

The benefit of a fistulagram is that it can give your doctors exact information regarding problems with your fistula and help them plan the best treatment for you. 

WHAT HAPPENS AFTER THE PROCEDURE?

After the exam is complete, you will be taken to our recovery room.  Once the heparin (a blood thinner given during the procedure) wears off, the Interventional Radiologist will remove the catheters from your fistula.  Pressure is held for 10-30 minutes on the insertion site to make sure that there is no bleeding.

Sometimes sutures are placed in the skin around the puncture sites because of the possibility of prolonged bleeding once you leave the Angio department. These are visible blue or black threads overlying the puncture zones in your dialysis graft.  There maybe 1,2, or perhaps even 3 of these sutures. These sutures only need to remain in place long enough for the puncture sites to heal.  At your next dialysis session, please ask your dialysis nurse to remove these sutures.  If for any reason he or she is uncomfortable in removing these sutures, please call us in the Angiography Division at (434) 924-9401 and we will arrange for you to return to us and have them removed.  It is very important that you have these sutures removed in 2-3 days.

WHEN CAN I GO HOME?

When you meet the discharge criteria, you may go home. To be discharged, your vital signs must be stable and your fistula sites should be clean and dry with no sign of bleeding.  In addition, you should be able to:

• Tell us your name, what the date is, and where you are

• Walk without getting dizzy

• Drink liquids and food without feeling sick to your stomach

• You will need someone else to drive you home.

WHAT TO DO AFTER I GO HOME?

Monitor your fistula frequently. A good thrill in your fistula indicates good blood flow through the vein. A good pulse in your fistula indicates good blood flow through the artery. You are the best person to judge how well your fistula is working. Also, have the dialysis nurse call us if they have difficulties using your fistula for dialysis.

If you have other questions or concerns about your fistula, write them down and call the UVA Angio/Interventional Radiology Department. One of the doctors or nurses will answer them for you.

FOR ANY QUESTIONS OR CONCERNS?

Please call the following numbers:

• Daytime (7:00 a.m. - 9:00 p.m.) Monday - Friday: (434) 924-9401

• Other times or on weekends and holidays: (434) 924-9400. Ask for the Angio/Interventional Radiology Fellow on call.

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