36821 Arteriovenous anastomosis, open; direct, any site (eg, Cimino type) (separate procedure)

Name of the Procedure:

Arteriovenous Anastomosis, Open; Direct, Any Site (e.g., Cimino Type) (Separate Procedure) Common names: AV fistula creation, Cimino fistula

Summary

An arteriovenous anastomosis is a surgical procedure that connects an artery directly to a vein, typically in the arm. It is commonly used to create an access point for hemodialysis in patients with kidney failure.

Purpose

This procedure addresses the need for a reliable vascular access point in patients requiring long-term hemodialysis. The goals are to ensure adequate blood flow for dialysis, reduce the risk of complications from other types of access points, and improve the effectiveness of the dialysis treatment.

Indications

• Chronic kidney disease or end-stage renal disease requiring hemodialysis
• Suitable vein and artery anatomy for connection
• Previous failure of other dialysis access types (e.g., catheters or grafts)

Preparation

• Pre-operative fasting as advised by the healthcare provider
• Discontinuation or adjustment of certain medications, such as blood thinners
• Pre-procedure imaging tests (e.g., ultrasound) to assess the suitability of veins and arteries
• Blood tests to ensure overall health status

Procedure Description

1. Anesthesia: Local anesthesia is applied to numb the area of surgery.
2. Incision: A small incision is made in the arm where the connection will be established.
3. Connection: The surgeon identifies a suitable artery and vein and then creates an anastomosis (connection) between them using fine sutures.
4. Closure: The incision site is closed with stitches or surgical staples.
5. Assessment: Blood flow through the new fistula is checked to ensure it is functioning properly.

Tools used: Surgical instruments, sutures Anesthesia: Local anesthesia

Duration

The procedure typically takes about 1 to 2 hours.

Setting

The procedure is usually performed in a hospital operating room or an outpatient surgical center.

Personnel

• Vascular surgeon or general surgeon
• Surgical nurses
• Anesthesiologist or anesthetist

Risks and Complications

• Infection at the incision site
• Bleeding or hematoma formation
• Thrombosis (clotting) of the new fistula
• Nerve damage near the surgical site
• Failure of the fistula to mature or provide adequate blood flow

Benefits

• Provides a reliable and durable access point for effective hemodialysis
• Lower incidence of infection compared to dialysis catheters
• Enhanced performance of dialysis treatments
• Can last for several years with proper care

Recovery

• Post-procedure monitoring in a recovery area
• Instructions to keep the arm elevated and avoid strenuous activities
• Pain management with prescribed medications
• Follow-up appointments to monitor the fistula’s development and function
• Initial healing period of 1 to 2 weeks, with full maturation taking 1 to 3 months

Alternatives

• Peritoneal Dialysis: Dialysis performed within the abdomen using a catheter.
• Hemodialysis Catheter: Temporary access via a central venous catheter.
• AV Graft: Using a synthetic tube to connect an artery to a vein, suitable for patients with small or unsuitable veins.

Pros and cons compared to AV anastomosis: Catheters are quicker to place but have higher infection rates; peritoneal dialysis offers more independence but requires rigorous daily management.

Patient Experience

Patients might experience some discomfort or mild pain at the surgical site, usually managed with pain relievers. Swelling and bruising are common initially. Most patients can resume regular activities after a few weeks, with specific instructions to protect the new fistula and promote its maturation. Regular follow-up ensures the fistula remains functional for dialysis use.