Patients of kidney disease must take fistula seriously

Dr KK Pandey *

In our country,you would have noticed a gradual and sustained increase in the number of patients suffering from kidney disease. You must have often heard in your friend circles or at your workplace, about the word 'FISTULA' and another word 'DIALYSIS'. You might have come across your relatives who have been taking their parents or elderlies in the family to hospitals for dialysis on a regular basis. This causes a lot of monetary expenses and mental stress.

A good fistula is essential for successful dialysis

Construction of a good fistula is of paramount importance for a successful dialysis. A dialysis machine is just like an artificial kidney. A dialysis keeps a safe level of some basic element like sodium, potassium and bicarbonate in the blood of a kidney patient. For a proper functioning of a dialysis machine, one requires a sustained blood flow of large amounts to and fro, at a high speed.

This is possible only with a successfully functioning fistula which is the only source of providing a large amount of blood flow at a high speed between minimum 300ml/minute and maximum 500ml/minute to the dialysis machine.

What is Fistula all about?

Fistula is a layman's term. In medical language, its full name is arterio-venous fistula (A-V Fistula). It's simple meaning is an artificial communication between a high pressure blood pipe (Artery) and a low pressure blood pipe (Vein). This A-V Fistula is constructed surgically by joining high pressure pipe with low pressure pipe.

For dialysis, you need two things, firstly a sustained flow of a large amount of blood a thigh pressure and secondly an easily accessible blood pipe in the upper limb. For that purpose, dialysis machine should ideally be connected to a high pressure blood pipe that is artery.

But sadly, all arteries are situated deeply and inaccessible being far away from skin surface and therefore putting a puncturing needle into this pipe to establish communication with dialysis machine is not possible. So we have to depend upon low pressure but easily accessible blood pipes (Veins) which are situated superficially just beneath the skin surface, and therefore being accessible and most suitable for easy puncturing.

For the purpose of dialysis, a low pressure vein has to be converted into a high pressure pipe, by connecting the accessible vein to a high pressure artery through surgery. After artificially establishing communication with an artery, a low pressure vein becomes the high pressure one and thus becomes suitable for conducting dialysis. Now you have understood what a fistula means,and why its construction is important.

Suitable sites for fistula construction in the body

There are a few suitable sites in the body where a surgical construction of a fistula is possible. The best site is the left wrist. The second best site is the left elbow. The reason being majority of our people are right handers and generally do not use their left hand for writing and other finer activities, that is why A-V fistula construction is preferred on the left hand. If construction of A-V fistula is not possible on the left hand either due to unfavorable anatomy or unsuccessful previous attempt at making fistula, the option of right upper limb is explored either at the wrist or right elbow.

Types of fistula

are of two types depending upon its anatomy. First type includes either R-C or B-C fistula. An R-C fistula (Radiocephalic A-V fistula) is constructed at the wrist in a single-stage surgery. Another one B-Cfistula (Brachiocephalic A-V fistula) is constructed at the elbow only after R-C fistula after construction has stopped functioning or due to anatomical difficulty, construction of R-C fistula is not possible.

The second type is B-B fistula (BRACHIO-BASILIC A-V fistula) which is constructed surgically in two stages. This B-B fistula is created only after B-C fistula construction is not possible due to anatomical difficulty. In the first stage, Brachial artery and Basilic vein are joined together surgically at the elbow. Then in the second stage, after 8 weeks, a fistulous vein is surgically brought forward under the skin to make it superficial for the purpose of dialysis. Always remember, the most preferable A-V fistula is R-C(Radiocephalic) fistula on the left wrist.

What to do, If all attempts to make any viable A-V fistula fail: -

If one after another A-V fistula construction fails successively and ultimately no proper site is available in the upper limb. In such situations where all attempts at making A-V fistula are exhausted, A-V grafting procedure is adopted. In this procedure, an artificial blood pipe is used in place of veins and surgically it is placed beneath the skin to make it accessible for the purpose of dialysis.

If A-V fistula and A-V grafting both fail

When all attempts to make either functioning A-V fistula or A-V grafting fail, the technique of permacath insertion is adopted. Permacath is an artificial catheter which is inserted directly into the central line in the neck and its other end is taken out from the chest wall. Generally, permacath is placed on the right side of the neck.

Current status of fistula construction in India

It has been observed,in small towns especially many kidney patients are advised for construction of A-V fistula by a general surgeon and sometimes by a plastic surgeon. This results, in majority of the cases, into failure of fistula and unnecessary avoidable scar in the skin. Sometimes two or three unsuccessful attempts are made at various sites in both the left and right upper limb. In some places, nephrologists( Kidney Physicians ) themselves make an attempt for construction of the fistula.

The surgical procedure of making an A-V fistula in India is woefully considered a highly underrated work. People should realize that a construction of A-V fistula is a very refined surgical work with high precision, and attempting to construct an A-V fistula by a kidney physician without any basic surgical training in this field is certainly not advisable.

Another disadvantage of non-functioning fistula and multiple unsuccessful attempts to construct it, is that the patient remains dependent upon artificial central lines in neck and groin for a longtime, as these lines are used temporarily for the purpose of dialysis. These body sites for central lines are more vulnerable for infection, if used for a longtime. It is not any easy talk to control infection in a kidney patient as he is already immune compromised with a very low defense system.

Where to go for fistula construction

Kidney patients for fistula construction must go to a hospital where there is an experienced full time Vascular surgeon and there should be a full-fledged department of Vascular surgery. Always choose preferably those hospitals where regular dialysis, and kidney transplant surgeries are done. Always remember that a Vascular surgeon is the only authorized competent surgeon all over the world for constructing an A-V Fistula.

* Dr KK Pandey wrote this article for The Sangai Express
The author is senior Vascular & Cardiothoracic Surgeon at Indraprastha Apollo Hospitals
This article was webcasted on November 14 2021.

* Comments posted by users in this discussion thread and other parts of this site are opinions of the individuals posting them (whose user ID is displayed alongside) and not the views of We strongly recommend that users exercise responsibility, sensitivity and caution over language while writing your opinions which will be seen and read by other users. Please read a complete Guideline on using comments on this website.

  • Imoinu Erat Thouni @ Koubru #2:: Gallery
  • COVID-19 Status 28 Jan : Govt of Manipur
  • COVID-19 : Impact in Manipur :: News Timeline
  • Living green makes sense: Go Green
  • In the stillness of the night :: Poem
  • A career in mining engineering
  • Pre-poll ticket tussle ... tension inevitable
  • The virus : Always one step ahead
  • Gaan-Ngai @Iboyaima Shanglen #3:: Gallery
  • COVID-19 Status 27 Jan : Govt of Manipur
  • COVID-19 Status 26 Jan : Govt of Manipur
  • Manipur Assembly Election (2007-2022) #1
  • World Meetei Council website launched
  • Homecoming of missing Arunachal youth
  • Winter vegetable that will give you glow
  • State hapless in preventing Omicron
  • The wait for the list continues
  • Republic Day @Kangla #1 :: Gallery
  • No matter what :: Poem
  • Fear of the virus
  • The Peace Forest Initiative
  • The vehicle for NEP 2020
  • Contribution of Leimayol Arts Centre
  • COVID-19 Status 25 Jan : Govt of Manipur
  • Lotus plant: A multipurpose plant species
  • Primary School renovated at Joupi
  • Republic Day recollections
  • Huge skills gap making new jobs go abegging
  • National Voters' Day
  • Lining up for BJP ahead of polls
  • Lainingthou Sanamahi Complex #2:: Gallery
  • COVID-19 Status 24 Jan : Govt of Manipur
  • BAMCHAS biennial conference 2022
  • COVID Vaccine Booster: To give or not
  • Before I sleep... III
  • Indian Army as a career option
  • 20-yr MoU to set up Mini-Grid in Nagaland
  • Season of promises!
  • Election curbs; relief for commoners
  • First manifesto, then candidates list
  • Imoinu @Yumnam Leikai :: Gallery
  • COVID-19 Status 23 Jan : Govt of Manipur
  • Our Ailing Planet: My locality as a facet
  • Stop Oil Palm Plantation in Manipur
  • General election in hard times :: Poem
  • Being free from freedom
  • Roaring 40 in first list of Cong
  • Significance of Gaan-Ngai festival #2
  • COVID-19 Status 22 Jan : Govt of Manipur
  • Wake Up My People Wake up :: Poem
  • A tribute to Athokpam Indrakumar Singh
  • Stunted fingerling- Replacement of fish seed
  • Training Program at Dimapur
  • Gaan-Ngai @Kakhulong :: Gallery
  • COVID-19 Status 21 Jan : Govt of Manipur
  • Classical Language Vs ST for Meetei
  • The Great Green Walls, conserving nature
  • Webinar: The Birds and Bees Talk
  • Covid Booster Campaign at Tamenglong
  • IVF Centre in Guwahati
  • Easing curbs as cases spiral
  • Third wave is on!
  • Ecotourism Complexes @ Ramrei :: Gallery
  • COVID-19 Status 20 Jan : Govt of Manipur
  • No excuse not to end acute pandemic stage
  • Palm-oil in Manipur: Bad to worse
  • For sons and daughters :: Poem
  • Effective methods for facial hair removal
  • Subdued dissent over Sunday as poll day
  • Embracing the party hoppers
  • Gaan-Ngai @Iboyaima Shanglen #2:: Gallery
  • COVID-19 Status 19 Jan : Govt of Manipur
  • Cultural Activists of Manipur honoured
  • Male infertility: What are the options ?
  • Is celebrating New Year Day really worth it
  • Third wave: State on record breaking spree
  • Compulsion of power politics
  • Imoinu Thouniba @Singjamei :: Gallery
  • COVID-19 Status 18 Jan : Govt of Manipur
  • O Jonga! O Jonga :: Poem
  • Grey market for election tickets
  • Some common weeds of Manipur #2
  • Lilong Haoreibi College awarded 'B' grade
  • State used as transport route of drugs
  • Possible post poll scenario
  • Significance of Gaan-Ngai festival #1
  • COVID-19 Status 17 Jan : Govt of Manipur
  • Lunghar path in springshed conservation
  • Lament of love :: Poem
  • Career options in Lift Technology
  • Brief tale of one year COVID vaccination
  • Bickering among allies in coalition politics
  • Low vaccination coverage
  • NH-2 : Remember Khongnem Thana
  • COVID-19 Status 16 Jan : Govt of Manipur
  • O Kolhen! O Kolhen :: Poem
  • Program on POCSO Act at Thoubal
  • The Killing Fields (2013-22) :: News Timeline
  • A spate of 'defections' in UP elections...
  • High performing individuals work alone
  • Onus on ECI to avert crisis situation
  • Keeping people informed is key
  • Gaan-Ngai @Iboyaima Shanglen #1:: Gallery
  • COVID-19 Status 15 Jan : Govt of Manipur
  • The church is & must remain apolitical
  • Tamenglong Battalion celebrated Army Day
  • How prosperous NE India became backward
  • Imoinu Erat Thouni @ Koubru #1:: Gallery
  • COVID-19 Status 14 Jan : Govt of Manipur
  • Read all about Gaan Ngai
  • Justice, Peace and Change :: Poem
  • Mass Surya Namaskar at Tamenglong
  • Padmanabha Swamy Temple
  • Overcoming vaccine hesitancy
  • Nothing grand about 'Grand Old Party'
  • Lainingthou Sanamahi Complex #1:: Gallery
  • COVID-19 Status 13 Jan : Govt of Manipur
  • A Hymn for Goddess Emoinu
  • Some common weeds of Manipur #1
  • How to keep your hair healthy this winter
  • Third wave: Litmus test for NE states
  • High TPR, low vaccination
  • Maharaja Gambhir Singh
  • COVID-19 Status 12 Jan : Govt of Manipur
  • Rani Gaidinliu Open Air Lounge inaugurated
  • NAAC peer team visit for assessment
  • National Youth Day
  • Conservation Agriculture: intensified farming
  • Negligence galore as Covid cases rise
  • Back to the spike in three figures
  • How AFSPA undermines 'Act East' Policy
  • COVID-19 Status 11 Jan : Govt of Manipur
  • P Achevei : Mega Mister North East 2021
  • Stop Violence related to Election
  • Civil / Project Engineer @ R-Square
  • Business Development @ R-Square
  • Customer Representative @ Property Geo
  • No matter what :: Poem
  • Stealthy extension of AFSPA
  • Confiscating 'suspected heroin'
  • 188 Death Anniv: Maharaj Gambhir:: Gallery
  • COVID-19 Status 10 Jan : Govt of Manipur
  • Biotechnology Ignition Grant (BIG) 20th Call
  • Kalum Kai (House of worship) #2
  • Account Assistant @ Amber & Arthur, Imphal
  • Business Dev @ Amber & Arthur, Imphal
  • The 5G Race :: Samarjit Kambam
  • Manipur elections not for the faint-hearted
  • Guns & violence in run up to polls
  • Climate Change in Ukhrul in last 50 years
  • COVID-19 Status 09 Jan : Govt of Manipur
  • Are we able to break chain of transmission
  • 100 new Sainik School- opportunities for girl
  • Joyjeet Waikhom / Ksh Maradona: Mr India
  • Money flying in or out ?
  • Will partial lockdown help curb transmission
  • Voting during Covid pandemic
  • Food items @ Singjamei, Pishum :: Gallery
  • COVID-19 Status 08 Jan : Govt of Manipur
  • Curfew : Measures to combat COVID
  • IMFP - Indian Made Foreign People
  • Happy 2022 to you !
  • Manipur Press Foundation Day :: Gallery
  • COVID-19 Status 07 Jan : Govt of Manipur
  • Politician must practice, preach on COVID
  • Makeup routine during pandemic
  • Third wave threat no more a mirage
  • Queuing up for BJP
  • Thangal Lambi & Ima Keithel :: Gallery
  • COVID-19 Status 06 Jan : Govt of Manipur
  • Before I sleep... II
  • Election Brawl :: Poem
  • Impact of Covid on Employer Branding
  • Chasing peace in Manipur
  • COVID-19 Status 05 Jan : Govt of Manipur
  • Kalum Kai (House of worship) #1
  • The art of New Year's resolution
  • Cong struggling to keep its house in order
  • Manipur's place in the eyes of Delhi
  • Makru bridge, Oinamlong Waterfall : Gallery
  • COVID-19 Status 04 Jan : Govt of Manipur
  • Depression : A New Time Bomb
  • School & Student Championship Quiz
  • Concern over child labour
  • ECI on sluggish vaccination rate in state
  • Vaccination rate in hill districts
  • Fusion of contemporary dance & theatre
  • COVID-19 Status 03 Jan : Govt of Manipur
  • COVID-19 Crackdown on violators
  • AMAND, Pune released 2022 calendar
  • Rising poverty in Manipur
  • Sunset, the most memorable!
  • Election time season of plentiful promises
  • Interesting role of NPP, NPF
  • Pineapple @ Ngariyan Hills #2 : Gallery
  • COVID-19 Status 02 Jan : Govt of Manipur
  • kLlQtre :: Seireng
  • National Day for our feathered friend
  • Value of purposeful life
  • Homemade face packs for winter beauty
  • Dreadful start to New Year as cases spike
  • Manipur steps into Year 2022
  • Tarpon Katpa @ Loktak #2 : Gallery
  • COVID-19 Status 01 Jan : Govt of Manipur
  • OneHealth: towards pandemic preparedness?
  • Before I sleep...
  • Meitei ST demand & the opposition
  • Bye Bye 2021 : Gallery
  • COVID-19 Status 31 Dec : Govt of Manipur
  • Featured Front Page Photo 2021 #6: Gallery
  • Manipur : National Futsal C'ship 2021
  • 'Unlocking Locks Under Lockdowns' released
  • Baby corn cultivation for livelihood
  • Extension of AFSPA to Nagaland
  • Hoping for a better New Year 2022
  • Appeal of AMCO to Chief Minister
  • NK Sanajaoba- Star in Dark Sky of Manipur
  • Danube Kangjam : Miss North East 2021
  • Armed Forces Special Powers Act, 1958
  • January Calendar for Year 2022 : Tools
  • Carol on Christmas :: Poem
  • Formation of 13 Farmer Producer Orgns
  • Indian Army Inquiry Team visits site in Oting
  • Review home isolation rule or punish violator
  • Lining up for saffron party
  • Red Ribbon Manipur Idol, 2021 #2: Gallery
  • Job-Fair 2021 @ Imphal : Gallery
  • Christmas Eve @ Imphal : Gallery
  • Christmas Eve @ Churachandpur : Gallery
  • Red Ribbon Manipur Idol, 2021 #1: Gallery
  • Heisnam Savitri (Legendary actress) #2
  • Painting: Tribal Freedom Fighter #1: Gallery
  • New Barak Bridge @Jiri highway : Gallery
  • Heisnam Savitri (Legendary actress) #1
  • RK Meghen tribute @ Nupi Lal : Gallery
  • Protest: massacre of Naga Brethen: Gallery