Initiating the AV Fistula Surgery Program in the Department of Urology at SDM Hospital, Jaipur

Within a few days of joining the Department of Urology at SDM Hospital, Jaipur, I realised the huge load of CKD patients being treated at the Department of Nephrology. Many of these patients were on maintenance hemodialysis, and had a requirement of AV fistula surgery. With prior experience of managing these patients during my surgical residency and fellowship, I felt the time was ripe to initiate the AV Fistula surgery program in our department. With the support of the Department of Nephrology and my seniors, we successfully performed our first AV Fistula in January 2021. Over the course of the next 5 months, we successfully performed 10 surgeries in 11 patients. Two radio-cephalic AV fistulae failed, both within the initial 3 cases. One of these patients underwent a successful brachio-cephalic AV fistula creation. Our cases included both radio-cephalic and brachio-cephalic AV fistulae and we increasingly felt confident in our program. At the same time, there were many learnings to be drawn from this experience, which I mention below.

1. Patient selection is of paramount importance. The 2 failures we faced had poor caliber vein on exploration. A careful pre-operative physical examination is essential in all cases, the caliber and compressibility of the cephalic vein needs to be assessed and recent needle pricks to be looked out for. The radial artery needs to be assessed for recent arterial lines or ABGs (as is the case with sick patients) and caution needs to be exercised in case of older patients and diabetics, as these patients may have thin and atherosclerotic arteries. Physical examination supplants a doppler investigation, which may turn out to be superfluous, both in terms of findings as well as cost, in case the physical examination is satisfactory.

2. Adequate patient preparation is essential. This needs to be done despite the logistic pressures of out-of-station patients and private healthcare costs. A poorly prepared hand is a recipe for failure. Soft ball exercises with the chosen hand, avoidance of intravenous injections and BP measurements in the hand planned for surgery are textbook necessities.

3. Inter-departmental cooperation and intra-departmental support is non-negotiable. Teamwork in these cases, as in all, only makes the program stronger. We plan to further expand our surgical repertoire (to more complex cases and basilic vein transposition) by holding webinars (in view of COVID-19 pandemic) and short surgical workshops.

4. Data-keeping needs to be done. We maintain a record of all the cases, along with their follow-up results and complications, if any. Record keeping helps in self-assessment and self-improvement.

5. A lot is to be learnt from the surgical assistants. For a new program, the experience and inputs of the surgical staff can be a game-changer, even if it involves minor modifications in dissection technique or Heparin dilution.

6. Technical nitty-gritties learnt during the procedure –

a. Insertion of feeding tube in the vein helps in spatulation and taking the corner stitch. After that the feeding tube may be removed and vein clamped with bulldog clamp to avoid interference due to the tube.

b. I take a stitch at either corner followed by continuous suturing of the posterior layer, followed by the anterior layer. While the distal corner stitch is knotted before beginning the posterior layer, the proximal corner stitch may be knotted after the posterior layer to help in taking the terminal bites.

c. The bulldogs may be used for clamping the artery during anastomosis, however, clamping the artery with vascular slings gives the advantage of stretching the artery a bit; this helps in suturing.