Arteriovenous (AV) Graft Procedure

Overview

An arteriovenous (AV) graft is vascular access created surgically for dialysis if you have been diagnosed with ESRD (End-Stage Renal Disease), which occurs when chronic (long-lasting) kidney disease reaches an advanced stage. With ESRD, you would need dialysis or a kidney transplant to survive since your kidneys can no longer carry out their filtering functions. Dialysis is a procedure of artificially removing waste products and excess fluids from the blood using a special machine (dialyzer) when your kidneys fail or stop functioning properly. AV graft helps provide vascular access by creating a connection between an artery (a blood vessel that carries oxygenated or pure blood from the heart to all parts of the body) and a vein (a blood vessel that carries deoxygenated or impure blood from all parts of the body to the heart) for dialysis. Needles are injected into the graft tube to divert the blood (from the venous end of the connection) to the dialyzer, which is filtered and returned to your body (through the arterial end of the connection).

Read more about AV graft, its recommendation, procedure, benefits, and risks. 
 

What is an Arteriovenous (AV) Graft?

An arteriovenous (AV) graft is a special medical device, a looped, thin, flexible plastic tube connecting an artery to a vein. The AV graft is usually placed in the non-dominant arm (e.g., if you are right-handed, it is placed in the left arm) but may also be placed in the leg (thigh) if required. The graft forms a connection between an artery and a vein, resulting in blood flowing from the high-pressure artery to the low-pressure vein. This blood flow provides a particular flow rate that would deliver enough blood to provide an adequate hemodialysis treatment . 

The graft used is a synthetic one or from a donor's vein. 

When is an Arteriovenous (AV) Graft Recommended?

An arteriovenous graft is often recommended when your kidneys fail to function properly due to chronic kidney disease that has advanced to the last stage, known as "End-Stage Kidney Disease" (ESRD). 

Though an AV fistula (a direct connection or link created between an artery and a vein) is the best choice of vascular access for hemodialysis, an AV graft would be recommended if you have small and unhealthy blood vessels where a direct connection would not be possible. 

Your surgeon may recommend an AV graft for kidney failure due to the following:

• Autoimmune diseases- These are disorders when your own immune system attacks healthy cells in your body (Lupus erythematosus)
• Certain inherited diseases- Diseases that are passed down through families or generations (Polycystic kidney disease).
• Conditions that reduce blood flow to the kidneys
• Illnesses that cause kidney inflammation- Include nephritis.
• Kidney cancer and trauma
• Infections- Including bladder infections or septicemia (blood infection).
• Medication abuse or overdose- Long-term use of NSAIDs (Nonsteroidal Anti-Inflammatory Drugs).

How to Prepare For an Arteriovenous (AV) Graft Procedure?

Your doctor will discuss your medical history regarding the duration of your kidney disease and the presence of any other medical conditions being suffered, such as diabetes (increased blood sugar levels), hypertension (high blood pressure), asthma, or other blood disorders. 

Be sure to inform your surgeon about the medications, including blood thinners, anti-inflammatory drugs, or other herbal or vitamin supplements. Your surgeon may recommend you to discontinue them before the procedure if necessary. 

There are a few tests to help determine the best location for the access, that include- Venography (a dye is injected to see the blood flow through the veins using X-ray images) and Doppler ultrasound scan (a scan that uses high-frequency sound waves to check the blood flow through the blood vessels). These tests are together known as "Vessel Mapping."

You must come for the procedure in loose, comfortable clothes and refrain from wearing any jewelry. You will be asked to sign a consent form before your surgeon begins the procedure to seek permission. 

How is an Arteriovenous Graft Creation For Hemodialysis Performed?

Arteriovenous graft creation is a safe, minimally invasive (does not involve large cuts or bleeding), and an outpatient procedure (does not require hospitalization) performed under local anesthesia that numbs the area to avoid any pain or discomfort. The procedure is as follows:

• Your nurse in charge will prep the area selected for incisions (cuts) by cleaning it with an antiseptic solution. This removes the surface contaminants to prevent any post-op infection.
• Local anesthesia will be administered to numb the area.
• An incision will be made between the blood vessels (artery and vein) with a scalpel (a surgical blade).
• Surgical tools will separate the artery and vein from the nearby nerves and tissues.
• Special clip-on surgical tools will be placed to secure both blood vessels to stop the blood flow.
• Tiny incisions will be made in the artery and the vein where the plastic tube (AV graft) will be inserted (one end at the artery and the other end at the vein).
• The AV graft will be secured to the blood vessels using stitches, the clip-on tools will be removed, and the blood flow will be checked.
• Stitches will be placed to close the skin incision. 
• A waterproof surgical dressing will be placed over the incision for protection. 
• The procedure takes around 45 to 60 minutes. 

What to Expect After an Arteriovenous (AV) Graft Procedure ?

After the creation of an AV graft, you will be kept under observation to check for the blood flows through the graft before being sent home the same day. 

• Mild pain, soreness, and discomfort are normal and can be managed through pain medications. This will subside in 2 to 3 days. If pain persists beyond 3 days, it is advisable to contact your surgeon for further evaluation. These medications may also cause constipation, so be sure to discuss with your surgeon about options, such as laxatives (stool softeners) to help with strained bowel movements. 
• You must keep your arm above the heart level to control swelling and ease discomfort. It is normal to notice some blood oozing from your dressing, but if you experience severe, yellowish drainage on the dressing, contact your surgeon immediately.
• You can expect to feel some "thrill,” "vibration," or " buzzing" sensation through the bandage. It is a normal sensation and means that the access is working, and the blood flows through it.
• You should be able to move your hand normally. If your hand becomes pale, numb, or turns blue, contact your surgeon immediately.

What Are The Benefits And Risks of an Arteriovenous (AV) Graft Procedure ?

An arteriovenous (AV) graft procedure is relatively safe and effective in providing vascular access for hemodialysis. Following are the benefits and risks associated with AV graft creation.

Benefits 

• It can be used ideally within 2 weeks of insertion.
• A good option when the veins are small and weak.
• It can be used during inadequate blood flow when it is difficult to create an AV fistula.
• It has a 2 to 3 years lifespan, which can later be replaced as and when required.

Risks

• Increased incidence of post-procedure infection around the AV graft.
• Blood clots may form that can get dislodged into the bloodstream and travel to internal organs causing life-threatening complications (clots in the lungs, heart, and brain). 
• Frequent thrombosis (a condition that occurs when the blood clots block veins or arteries).
• AV graft dysfunctioning and failure.

What is The Prognosis of an Arteriovenous (AV) Graft?

An arteriovenous (AV) graft creation is a safe procedure with a lifespan of 2 to 3 years. AV grafts can be safely used within about two weeks of insertion since no maturation of the blood vessels is required. An AV graft's overall successful access rate ranges up to 95%, with a failure rate of around 5% for the upper extremity (arm) and 12.6% for thigh grafts.

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