​​​​​​​Case Share | Balloon Angioplasty after Arteriovenous Fistula Creation

Release time:

2024/01/23


Case Share | Balloon Angioplasty after Arteriovenous Fistula Creation

 

Patient Information: Male, 79 years old

Preoperative Diagnosis: Stenosis of artificial arteriovenous fistula, Stage 5 chronic kidney disease, uremic cardiomyopathy, renal anemia, hypertension, First-degree atrioventricular block, Atrial premature contraction (atrial premature beat), Simple renal cyst, Multiple hepatic cysts, Gallbladder stones

Anesthesia Method: Local Infiltration Anesthesia

Surgical Procedure: Ultrasound-Guided Balloon Angioplasty after Arteriovenous Fistula Creation (Used for renal dialysis)


Preoperative Assessment:

Ultrasound examination revealed local stenosis above the anastomosis of arteriovenous fistula, with a minimum inner diameter of 1.5mm. Colorful high-velocity blood flow was observed at the narrow vein blood vessel.

After examination, perform ultrasound-guided balloon dilation therapy following arteriovenous fistula creation.

Short-axis view of arteriovenous fistula creation in 2D mode

Long-axis view of arteriovenous fistula creation in blood flow mode

Surgical Procedure:

The patient was placed in a supine position with the left forearm in an abducted position. Standard disinfection and draping were done at the puncture site. Under ultrasound guidance, 2% lidocaine was locally infiltrated at the puncture point. A puncture needle was inserted into the left forearm vein, and blood from the internal fistula rushed out. A guidewire was inserted, the needle was withdrawn, a 5F sheath was inserted, and 20mg of heparin was intravenously injected.

Catheter insertion

Guide wire insertion

Ultrasound showed local stenosis above the anastomosis of the internal fistula. Under ultrasound guidance, a 0.89mm super slippery guidewire smoothly passed through the narrow area. A 5mm balloon catheter was advanced to the stenotic site.

Monitoring position after guide wire insertion

First balloon catheter expansion

Using a balloon inflation pressure pump under real-time ultrasound scanning, the blood vessels were gradually dilated in stages, with 10-16 atmospheres of pressure applied 5 times, each lasting for 15 seconds. Post-dilation ultrasound showed an inner diameter of approximately 3.5mm at the narrowest point. The puncture site was compressed and bandaged. The procedure was smooth, and the patient had no obvious discomfort. Auscultation revealed a loud murmur at the internal fistula.

Evaluation after balloon dilation

Second dilation balloon catheter entry

Ultrasound Doppler mode was used to observe the changes in the diameter and blood flow of the veins before and after the procedure. Manual or automatic blood flow measurements were performed to assess vascular blood flow.

Before balloon dilation

After balloon dilation

Intraoperative pictures:

Medical Tips:

Arteriovenous fistula surgery, commonly known as fistula creation or AV fistula, involves artificially establishing a short circuit between the artery and vein using vascular surgical techniques. This provides a long-term and effective vascular access for extracorporeal circulation during blood dialysis. Matured over time under the high-flow, high-pressure, and high-velocity blood flow impact of the artery, the vein undergoes thickening of the vessel wall and widening of the vessel lumen. When blood dialysis is required, the vein blood vessel can be immediately punctured for blood dialysis treatment, thereby saving lives. Therefore, arteriovenous fistula is also known as the "lifeline" for dialysis patients. The direct anastomosis of the distal radial artery and cephalic vein in the forearm is the preferred long-term vascular access for dialysis patients.

Vascular stenosis is the most common complication after arteriovenous fistula surgery. Endothelial hyperplasia and thrombus formation cause progressive stenosis and thrombus formation in the venous outflow tract, ultimately leading to occlusion and the inability to perform dialysis.

Ultrasound-guided balloon angioplasty is a new technique for treating vascular stenosis after arteriovenous fistula surgery in dialysis patients. It offers advantages such as precision, minimally invasive, real-time guidance, no radiation damage, minimal vascular damage, short surgery time, and short postoperative recovery period. In recent years, it has gradually been widely used. It involves percutaneous puncture of blood vessels under ultrasound guidance, real-time ultrasound scanning to observe the introduction of balloon dilation catheters into blood vessels, dilation of the narrowed part of the blood vessels, restoration of the normal inner diameter of the blood vessel lumen, and maximum preservation of the patient's vascular resources. This procedure prolongs the lifespan of the current vascular access and is currently the most advanced method for improving stenosis/occlusion of arteriovenous fistula in dialysis patients.