Percutaneous endovascular forearm arteriovenous fistula creation for haemodialysis access

Evidence-based recommendations on percutaneous endovascular forearm arteriovenous fistula creation for haemodialysis access in adults. This involves using radiofrequency energy, or heat and pressure, to join an artery and vein in the forearm to create a fistula for haemodialysis access.

# Recommendations
Evidence on the safety of percutaneous endovascular forearm arteriovenous fistula creation for haemodialysis access raises no major safety concerns. However, evidence on its efficacy is limited in quantity and quality. Therefore, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research. Find out what special arrangements mean on the NICE interventional procedures guidance page.
Clinicians wanting to do percutaneous endovascular forearm arteriovenous fistula creation for haemodialysis should:
Inform the clinical governance leads in their healthcare organisation.
Give patients (and their families and carers as appropriate) clear written information to support shared decision making, including NICE's information for the public.
Ensure that patients (and their families and carers as appropriate) understand the procedure's safety and efficacy, and any uncertainties about these.
Audit and review clinical outcomes of all patients having the procedure. The main efficacy and safety outcomes identified in this guidance can be entered into NICE's interventional procedure outcomes audit tool (for use at local discretion).
Discuss the outcomes of the procedure during their annual appraisal to reflect, learn and improve.
Healthcare organisations should:
Ensure systems are in place that support clinicians to collect and report data on outcomes and safety for every patient having this procedure.
Regularly review data on outcomes and safety for this procedure.
Patient selection should be done by a multidisciplinary team including a vascular access surgeon, nephrologist and interventional radiologist.
Report any problems with a medical device using the Medicines and Healthcare products Regulatory Agency's Yellow Card Scheme.
NICE encourages further research, preferably randomised controlled trials, into percutaneous endovascular forearm arteriovenous fistula creation for haemodialysis access. This should report details of patient selection, particularly about vascular anatomy, technique used, need for training, patency of the fistula and its subsequent ease of use, and quality of life.# The condition, current treatments and procedure

# The condition
Chronic (long-term) haemodialysis is used to treat advanced chronic kidney disease in many people who have renal replacement therapy.

# Current treatments
An arteriovenous fistula is considered the best type of vascular access for haemodialysis. The preferred way of creating such access is to surgically join an artery and vein together in the distal forearm (radiocephalic fistula). However, other anatomical sites may be used. Alternative surgical approaches for vascular access include arteriovenous grafts and placing tunnelled catheters into a large vein. A minimally invasive, percutaneous, endovascular procedure is another way of creating an arteriovenous fistula.

# The procedure
This procedure can be done using different systems, and is usually done in a day-case facility under local anaesthesia, with or without conscious sedation. Using ultrasound or fluoroscopic guidance, 2 small needles are inserted into an artery and a vein in the proximal forearm, that is, the radial, ulnar or brachial artery and adjacent vein. Thin, flexible, specially designed catheters are then advanced and positioned by guidewires in the chosen vessels. The catheters are aligned close to each other (using inbuilt magnets or mechanically, depending on the system). The arterial and venous walls are then fused side to side using heat and pressure, or a small burst of radiofrequency energy released from the catheters. This creates an arteriovenous fistula between the target vessels. The catheters are then removed. High-flow arterial blood passes through the vein and, with time, it arterialises. This allows needles to be inserted into the vein to provide vascular access during haemodialysis.
The exact technique may vary slightly depending on the device used.