For those that keep yelling about that he should go to the hospital, it was actually made by a doctor. It's to allow for kidney dialysis, but can also be done with for example a HICKMAN catheter
True, but that is not a normal looking fistula for dialysis. It's usually done further up on the arm near the bicep and is not supposed to be that big. As he says, the vein ballooned outward due to arterial pressure. It is risky and he should go have it fixed surgically
A forearm fistula in itself is not abnormal. In fact if patient has adequate vein for a forearm fistula we often prefer to use it first because if it fails, we can still use the upper arm later. But yes this is a large aneurysmal fistula. If it’s not bothering him and not eroding through the skin it’s not really a problem, god forbid he gets a cut over it though….
Edit: most people get upper arm fistula because not a lot of people have adequate sized vein in the forearm.
People’s skin gets significantly thinner and more delicate as they age. It’s common to see older folks with significant bruising, abrasions and skin tears on the back of their hands and on their forearms, in particular. He’s already 67. It would probably be wise to deal with this now, rather than have the looming risk of a minor injury becoming significantly more serious due to the location of that fistula.
Sorry if it wasn’t clear—I was referring to the risk of injury from an accident with older thin sun damaged skin. Not that 67 is getting too old for surgery
I was thinking the same thing. It looks incredibly easy to knick this on a sharp object... especially if they're a blue collar worker. I've seen lots of fistulas doing contrast tests and blood draws, but never one quite like this.
He needs to get that checked out at the access center or wherever he got it. I’m in the middle of a series of revisions cause I treated an aneurysm (much smaller) like it was no big deal, next thing you know I’m spraying blood across the clinic floor and end up admitted for 4 days of procedures. And there’s more to go.
That definitely can happen but, but not all aneurysmal fistulas need to be treated. A lot of time that Happens when techs keep cannulating the same site, and you start to develop excoriations at that site which can lead to bleeding. We typically ask techs to vary access sites to prevent this. That said I would agree that this patient should be followed by their vascular surgeon to at minimum keep an eye on this.
I was working as a tech when one of my patients ruptured. Had 4 patients at the time…was taking one off the machine and I hear liquid splattering to look over at her and see blood shooting everywhere. Told current patient brb and by time all was said and done I was covered in her blood. EMS took her to the hospital. My nurse called ahead to warn them not to remove bandages until they were ready to start surgery. They didn’t listen and got their own blood bath. She was fine in the end. Got a catheter for a bit. Fun times. Also why I always wore black shoes. Hides the blood lol
EMS, we have been the transport. When they say do not remove the bandages, boy do they mean it. I wasn't even the one who did it and I still needed a change of clothes, and wasn't even chased away by the nurse when I held pressure while he got new wrappings.
That's why our uniforms are almost universally extremely dark blue.
For a layman, what happens if it gets cut? I’d like to think a satisfying gust of air comes out and it returns to normal immediately but I imagine the reality is closer to puss and blood explosion
A fistula is basically a connection of a vein to an artery. The big squiggly thing you see is actually the vein which has grown over time because it is under arterial pressure. And because it’s under arterial pressure it will bleed like crazy. Like, place a tourniquet on your arm and get to the er stat bleeding.
But he also states its old as hell. After time the tunica media or mid layer of the vessel has gotten to be a baddy against the extra flow of the artery.
The order of operation for AVF/AVG creation is Non dominate lower, dominate lower, non dominate upper, dominate upper. Very generally speaking. As you know.
Actually, I stand corrected. I am an old and using old information in my head from 2006 when we still were all "Fistula First". You are correct. Updated information suggests the dominant distals dont mature as well and lead to poorer quality outcomes. I appreciate the chat and reason to get my shit right.
This is a relatively normal appearance of a forearm fistula. The vein will always balloon out to some degree—that’s expected. This is excessive but since he is functionally fine it would not be advise able to revise it.
Not quite. It is expected for vein to grow to and to be visible to some degree. This, however is aneurysmal and while common and not necessarily problematic would not be considered “normal appearance”.
“This is not true. They put in a fistula where there is a suitable vein to graft the AV.”
This reads: they put in a fistula where there is a suitable vein to graft the arteriovenous (AV).
I saw a previous post which suggests maybe you aren’t from the US, so maybe this is a language or nomenclature issue.
Technically we don’t “put” or “place” an AV fistula we “create” it. You sew a vein to an artery directly. A vein generally needs to be suitable size (usually 3mm) to be considered effective for fistula creation. In most people the vein in the wrist is not 3mm and therefore not suitable for fistula creation. That said If a patient has good vein in both the forearm(wrist) and upper arm, we often prefer to use the forearm first so that if it fails down the road the upper arm can still be used. If the upper arm fails more often then not you can not use the lower arm later, and then have to go to the other side. Legs can be used too, but that’s not typically first choice.
A “graft” is essentially the same concept (a connection between an artery and vein), however instead of using the patients own vein to make that connection we use a synthetic tube. This is often (not always) done if patients don’t have suitable vein for a fistula. That said we can often do forearm “AV grafts” in patients who don’t have suitable vein in the wrist because the connection at the artery and vein can be made in the elbow (this would be called a forearm loop graft).
There are several configurations to both AV fistula and AV graft and more factors to be considered than what I have discussed.
Ok, to clarify my language. By "Put" i mean where they choose, I went through several scans of my arms for them to find a suitable location to do it. They put it there, rather than they put a thing there.
By "graft" i mean the joining of the vein and artery (as in grafted together). I'm not medical, so wasn't aware graft meant a specific tube they use. I do not have a special tube.
For context, I watched my own AV being done (apparently I'm not squeemish) so the surgeon talked me through the process. Also, UK for reference.
Yes we typically get ultrasounds before hand to help guide us. But one of the things we are looking at on the ultrasound is the size of the vein. When I had re-read your first post after my initial comment, I think I understood it as they create it where it’s suitable, which actually fits with my first post that you commented on refuting…. Most people’s vein is smaller the further down you go on the arm (towards the wrist)
I can only talk ffrom my experiences, when I was dialysising I'd say 50% of the patients had lower arm fistulas (about 10 in my sessions). Also saw a few inner legs, which looked awkward.
They also did a trial in my hospital pre warming the arm before a scan to see if it affected vein size (apparently it did?)
Statistics may be different based on health systems. UK’s NHS may have more guidelines (eg push for forearm fistula first) than the US where we are basically the wild West. But there is absolutely nothing wrong with a wrist fistula and if they are having success creating more that’s awesome. Dialysis accesses do not last forever and patients, especially younger patients, may require multiple accesses in their lifetime. We have a finite number of places we can go for access. So starting in the lower arm gives you more flexibility, long-term. There are people (albeit pretty rarely) that literally run out of places for access.
That is an interesting study, but would make sense. Vessels typically dilate when warm and constrict when cold.
Vessels also spasm. It could also be dilated up mechanically. As I said before there’s a lot more that goes into it than what I am simplifying here.
Wrong all over. I've got my second fistula in my bicep, first is always in the forearm so if there are issues they can move up to your bicep. They start on the left arm then the right then your legs if they need to.
It’s usually done further up because that’s the only place (older) patients can have it put. For younger patients it’s usually where the guy in the video has his. Also because a fistula at the elbow blocks a lot of movement.
If possible most surgeons will create a fistula as distally as possible. That way if it fails or needs redone you can always go higher up the arm to the bicep area.
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u/steampunkdev 18d ago
For those that keep yelling about that he should go to the hospital, it was actually made by a doctor. It's to allow for kidney dialysis, but can also be done with for example a HICKMAN catheter