Access Excision
"Access excision”, image #1
The first step is to expose the fistula from end to end
"Access excision”, image #2
Once the fistula is exposed, it is skeletonized, ligating and dividing all branches from end to end. Finally, both ends will be ligated, and the fistula excised.
"Access excision", image #3
The incision, the excision.
"Access excision", image #4
When this incision is healed it will be invisible. How much better than a lumpy thrombosed fistula?
More often than you think, we are confronted with the dilemma of what to do with an unused fistula. Most often, the patient has had a renal transplant and would like to get rid of the “lumps” in his arm, and most often we advise the patient not to abandon a perfectly good asymptomatic fistula. You never know how long a transplanted organ is going to last, and you never know when you are going to need that fistula again.
The problem is that fistulas do not stay the same and maintenance is required in most cases. How much trouble having maintenance done is reasonable to keep an unused fistula going? The factors include the likelihood that the transplant will fail and the patient needs to return to dialysis (borderline function, older donor, poor match, episodes of rejections, episodes of viral illnesses, versus younger donor, great organ function, better antigen match, no rejection, no viral problems), combined with (1) the degree of symptoms from the fistula, (2) the intensity of maintenance required to keep the fistula going, and (3) the existence of other fistula options should the existing access option be lost. The calculation is different for each patient.
With this patient, the fistula was placed for plasmapheresis, which became unnecessary soon after the fistula was released. Had I known the future, I would not have recommended the procedure (nor married my second wife), but I don’t know the future …… fortunately. He came complaining of a degree of bothersome digital ischemia, and symptoms of shortness of breath suggesting that his fistula was taxing his heart. I agreed to ligate the fistula.
The problem with simple ligation of a sizable fistula is that the fistula turns into a dependent “sock” in the arm, and fills up with blood by gravity when the arm hangs down. When this pooled blood clots in the static fistula, it becomes an inflamed mess, like a giant hemorrhoid on the arm. Experience has taught me that, as daunting as a ten-inch incision might be, it is actually the quickest and least complicated way to the most satisfactory result.
