Arteriovenous (AV) fistula in Jordan
الوصلة الوريدية الشريانية لمرضى غسيل الكلى
An arteriovenous (AV) fistula is a small operation in which a vascular surgeon joins an artery to a neighbouring vein in the arm — at the wrist, in the forearm or in the upper arm. Over the following weeks that vein carries arterial pressure and flow, its wall thickens and its diameter grows, so it can be punctured with two needles at every haemodialysis session, repeatedly, without collapsing. Of all the ways of reaching the bloodstream for dialysis, a fistula built from your own vessels lasts the longest and carries the lowest risk of infection, which is why it is preferred over a central venous catheter whenever the veins are suitable. A fistula is usually created well before long-term dialysis is actually needed, because it does not work immediately: it requires a maturation period. The decision starts with a clinical examination of the pulses and the blood pressure in both arms, together with ultrasound mapping of the arteries and veins, so that the surgeon can choose the most distal suitable site and keep the sites nearer the shoulder in reserve for later years of treatment. If your own veins are not suitable, the surgeon will discuss alternatives such as a synthetic graft or a tunnelled catheter. Each option balances speed of use against the risk of infection and clotting, and the trade-off should be explained to you before the decision, not after it. It matters just as much to know what this operation does not do. A fistula creates a durable route for dialysis; it does not treat kidney failure itself, it is not a substitute for transplantation, and it cannot be used on the day it is made. Not every fistula matures: some need a catheter procedure to widen a narrowed segment, and some are abandoned in favour of a new site. Whether you are a candidate, and where, is decided by clinical examination and imaging — not by reading.
Procedure steps
- 1
Vascular assessment and vein mapping
The surgeon examines the pulses and blood pressure in both arms and orders a duplex ultrasound that measures the diameter of the veins and arteries and assesses the quality of their walls and their course. Veins scarred by previous cannulation are avoided, and the most distal suitable site is chosen so that sites nearer the shoulder remain available in future.
- 2
Preparation and anaesthesia
The arm is cleaned and carefully draped. The operation is usually performed under local anaesthesia or with a regional block around the nerves of the arm, so in most cases you stay awake. Pulse, blood pressure and oxygen saturation are monitored throughout, and you can tell the team straight away about any uncomfortable sensation.
- 3
Creating the arteriovenous connection
Through a small incision the surgeon frees the chosen vein and artery, then sews the opening of the vein onto the opening of the artery with very fine sutures so that arterial blood is diverted into the vein. The size of the connection is judged with care: too small and the fistula will not mature, too large and it may steal blood from the hand.
- 4
Checking flow and hand perfusion
Once the clamps are released, the surgeon feels a thrill along the vein and hears a bruit with a stethoscope, and confirms that the hand is warm and pink with a preserved pulse and normal movement. If flow is poor, or the hand turns pale, the size or the site of the connection may be revised during the same operation.
- 5
Closure, maturation plan and follow-up
The wound is closed in layers and covered with a light dressing, and you usually go home the same day. Follow-up visits are arranged to assess maturation clinically and with ultrasound, and the date of the first cannulation is agreed with the dialysis unit. Any temporary catheter continues to be used until the fistula is genuinely ready.
Before the procedure
Tell the doctor about every medicine you take, especially blood thinners, anticoagulants and diabetes medicines, and do not stop anything on your own — wait for clear written instructions. Start protecting the planned arm today: no blood samples, no intravenous lines and no blood-pressure cuffs on it, and tell everyone treating you that this arm is being saved for a fistula. Bring your blood sugar and blood pressure under control before the appointment. Stop smoking; it narrows the vessels and reduces the chance that the fistula will mature and last. Wash the arm well and report any cut, rash or skin infection. Follow the fasting time given by the anaesthetic team, arrange your dialysis sessions before and after surgery with your unit, come with someone who can take you home, and remove rings, watches and bracelets.
After the procedure
Rest the arm on a pillow for the first few days and move your fingers regularly. Do not sleep on the arm, do not lift heavy weights with it, and do not wear a watch, bracelet or tight sleeve over it. Never allow blood-pressure measurement, blood sampling or a drip in the fistula arm, and carry a card that says so. Check the fistula yourself every day by resting your fingers on it to feel the thrill. Do the hand-grip exercises your surgeon recommends, only after explicit permission. Keep the wound clean and dry and shower the way your team advises. Seek care immediately if: **the thrill or bruit over the fistula disappears** (possible clotting — the first hours decide whether it can be saved, so do not wait for your appointment) · **the hand becomes cold, pale, severely painful or weak** (possible hand ischaemia — this is an emergency) · bleeding from the wound or a needle site does not stop with continuous pressure · there is fever, spreading redness, pus or increasing pain · the whole arm, or the face and neck, swells · **a leg suddenly becomes painful, swollen and warm** (possible deep vein thrombosis — do not massage the leg and do not wait), and if **chest pain or breathlessness** is added, go straight to the emergency department.
Expected duration
The operation itself usually takes one to two hours and is most often a day case. Maturation before the first cannulation typically needs six to twelve weeks, sometimes longer depending on the veins, and readiness is judged by examination and ultrasound rather than by the calendar alone.
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