You have been referred to Michigan Vascular Access for treatment of your vascular access.

Your access is not performing as well as expected, or is not developing as quickly or as well as expected, or a complication has been noted with your access.

After our evaluation, you have been advised to undergo a fistulogram for diagnosis of the problems with your graft or fistula. This procedure is done in the operating room with the aid of fluoroscopy (x-ray imaging). After numbing a spot over your graft or fistula, a needle or small plastic tube will be placed in the access and x-ray dye ("contrast") injected. Depending on the findings, a narrowing may be stretched with a balloon ("venoplasty"), a stent may be placed to prop open a narrowing that does not stay open after ballooning, a stent may be placed to patch a hole in the graft, or clot may be removed from the inside of the access. Sometimes more than one puncture in the access is necessary.

The anticipated benefit of this procedure is a safer, more effective, more long-lasting form of vascular access than you now have, or to provide the most effective form of an access that you will need in the future, or to manage problems with your existing access.

Optimizing your vascular access for dialysis is important, as up to 20% of deaths in the dialysis population are attributed to insufficient access or complications of vascular access.

Delay in replacing a catheter with either a well-functioning graft or fistula increases the risk of central stenosis (ruining the large veins near the heart), or catheter infection.

The specific benefit of endovascular procedures is that generally no incision is required, and the x-ray imaging allows the surgeon to assess more of the graft and circulation than is possible through an incision.

There is no perfect or problem-free operation in vascular access. It is important to know that problems can and will occur to a certain percentage of patients. Most of these problems can be managed and corrected safely. Others will require major efforts, and some can result in permanent injury. You should understand and accept these risks before proceeding with any operation.

Every operation that requires an incision or puncture carries a certain risk of infection and bleeding. The risk of infection with percutaneous or "endovascular" procedures (done only through punctures and not with incisions) carries much less risk of infection, and generally antibiotics are not given.

Because percutaneous or "endovascular" procedures require injection of x-ray dye ("contrast") in order to see the blood vessels on x-ray, there is a risk of allergic reaction. Allergic reaction may cause itching and a rash, or may cause difficulty breathing, drop in blood pressure, or death. Notify us now, and again in the hospital, if you have ever had an allergic reaction to x-ray contrast, iodine, or seafood. Allergies to other medications and substances may be important - discuss all your allergies with the health care team. In most cases, medication can be prescribed to reduce these risks, or alternative forms of treatment chosen.

Bleeding can occur during the operation, or afterward. Bruising is common, and resolves within weeks of the operation. A hematoma (collection of blood under the skin) may occur. These generally also resolve on their own in weeks. Occasionally, an operation may be recommended to drain the blood or tissue fluid. Rarely, such a collection may become infected and may require drainage.

Stretching a narrowing in the circulation with a balloon ("venoplasty") is performed to correct a narrowing or blockage in your access. Occasionally, the access may be ruptured with the stretching of the balloon. Many such ruptures are limited, heal on their own with no consequence, and cause temporary bruising or a stable hematoma. Occasionally a pseudoaneurysm (a pocket or bubble extending off the side of a graft or fistula) may be the result, and require a corrective procedure.

Other ruptures lead to ongoing bleeding outside the graft in the tissues (an expanding hematoma). Treatment options include stopping the blood flow in the graft to stop the bleeding (a "ligation" performed through a small incision), or patching with a teflon-covered wire tube (a stent).

Stretching a narrowing in the circulation with a balloon ("venoplasty") may lead to a temporary or permanent correction of a problem with your access, or the narrowing may come back within weeks or months. Repeat procedures are some time necessary. Sometimes a stent may be placed to prop open a narrowing that does not stay open after ballooning, or which comes back within weeks or months after ballooning.

Any type of sedation or anesthesia during procedures carries risk. The sedated patient may not breathe deeply enough. Although uncommon, respiratory insufficiency may cause a "blue alert" requiring temporary help from the ventilator (breathing machine), or even lead to a cardiac arrest. Anesthesia may reduce the blood pressure and affect the circulation. Although uncommon, cardiac arrest or stroke may occur in the operating room just as easily as they can occur while you are walking the dog or shoveling snow.

Most grafts and fistula derive their blood supply from the arteries of the arm. Some of the blood intended for the hand is diverted into the graft or fistula. In most cases, the hand still gets enough blood, and no problem occurs. Occasionally after an endovascular procedure, a patient may notice "pins and needles" sensations in the hand, occasional mild numbness, or coolness of the hand in the arm where an access has been created (called "steal"). This is normal, and usually resolves over time. Keeping the hand warm with a glove usually helps. However, steal can be more serious, and can lead to long term or permanent disability. If the hand becomes severely numb, severely cold, painful or if there is any loss of grip strength or mobility that is not corrected by warming the hand, the surgeon should be notified immediately. A corrective procedure may be recommended, or the blood flow in the access may be eliminated to return all the blood to the hand. Delay is unwise.

Rare and unforeseen complications can occur – after your surgery you should discuss any new symptoms with your doctor, whether you believe they are associated with the surgery or not.

Although grafts and fistulas are usually spoken of as "permanent access", for most people there is no such thing. Everything wears out in time, and everything worth having requires some looking after. Often, endovascular procedures are maintenance procedures, and like all maintenance (think home or automobile maintenance) may need to be repeated at regular intervals. The dialysis center will look out for problems with your access and refer you for a corrective procedure when indicated. The patient and family can also be alert for problems and seek help before serious consequences occur. Please refer to Michigan Vascular Access's "Warning signs for grafts and fistulas". Well-maintained grafts and fistulas will last longer and give fewer problems than neglected grafts and fistulas.