Fistulas and Shunts

Group 26
Cheppela, Anjana
Morgia, Sherika
Palathinkal Afsal, Farhan
Toting, Mae Kris
 FISTULA
• ABNORMAL communication between lumen of one
viscus and lumen of another (INTERNAL FISTULA)
(or)

between lumen of one hollow viscus to the exterior

(EXTERNAL FISTULA)

(or)
between any two vessels
 Fistula
• EXTERNAL: • INTERNAL:
-Orocutaneous -Tracheo-esophageal
-Enterocutaneous -Colovesical
-Appendicular -Rectovesical
-Thyroglossal -AVF
-Branchial -Cholecystoduodenal
 Fistula - Causes
• CONGENITAL • ACQUIRED
Branchial fistula Traumatic
Tracheo-esophageal Inflammatory
Umbilical Malignancy
Congenital Iatrogenic
AV fistula
Thyroglossal fistula
 Fistula
TRAUMATIC

(A) following surgery : eg., intestinal fistulas

(faecal,biliary,pancreatic)

(B) following instrumental delivery (or) difficult

labour e.g., vesicovaginal,rectovaginal,
ureterovaginal fistula
 Fistula
INFLAMMATORY: Intestinal actinomycosis, TB III.

MALIGNANCY: when growth of one organ

penetrates into the nearby organ. e.g., Rectovesical
fistula

IATROGENIC: Cimino fistula- AVF for hemodialysis,

ECK fistula - to treat esophageal varices in portal
HTN
Common Types of Fistulas
ANAL FISTULA
ANAL FISTULA
ANAL FISTULA
Enterocutaneous Fistula
Enterovaginal
Enterovesical fistula
Tracheoesophageal Fistula
 Fistulogram
• A fistulogram uses a form of real-time x-ray called fluoroscopy
and a barium-based contrast material to produce images of an
abnormal passage within the body called a fistula
 Fistulogram demonstrating narrowing involving the ileocaecal
junction and the terminal ileum, and a fistulous communication
between the terminal ileum and the skin
 Fistulotomy
• The most common type of surgery for fistulas
is a fistulotomy. This involves cutting along the
whole length of the fistula to open it up so it
heals as a flat scar.
 Bioprosthetic plug
• Another option in cases where a fistulotomy
carries a high risk of incontinence is the
insertion of a bioprosthetic plug.
• This is a cone-shaped plug made from animal
tissue that is used to block the internal
opening of the fistula.
 Fistulectomy
• Fistulectomy is a surgical procedure where a
fistulous tract is excised (cut out) completely.
This is compared with fistulotomy, where the
fistulous tract is merely laid open to heal.
Arteriovenous (AV) Fistula
 The Gold Standard - Hemodialysis Access

• It has a lower risk of infection

• It has a lower tendency to clot
• It allows for greater blood flow and reduces
treatment time
• It stays functional longer than other access
types
• It’s usually less expensive to maintain
 Procedure
• Establish AV fistulae when the patient has an estimated GFR of 15 to 20
ml/min and progressive kidney disease.
• - AV fistulae need time to mature before cannulation (at least one month,
preferably 3 mo).

• General Principles:

• Preferable to use the arm vessels rather than leg vessels. When possible,
the non-dominant arm.
• Access site should be placed as distal as practical in the limb, so that
proximal sites will be available for subsequent procedures.
• Inadequate or atherosclerotic arteries should be avoided, and a long
section of patent vein is required to accomodate multiple cannulation site.
• Prophylactic antibiotics are used for all cases involving insertion of
prosthetic material.
 Procedure
• Preservation of access vessels
• The autogenenous AV fistula at the wrist is the
procedure of choice.
• Most second choice procedures also make use of the
forearm , with the principle access vessels being the :
– Radial – brachial artery
– Cephalic and cubital fossa veins
• So these vessels should be preserved by avoidance of:
– Venipuncture
– Intravenous cannulation
– Invasive monitoring lines
 Procedure
• Procedure choices in vascular access surgery
• First choice:
– Radiocephalic direct AV fistula
• Brescia-Cimino (wrist)
• Snuff-box (base of the thumb)
• Second choice:
– Forearm AV graft bridge fistula
• Straight : radial artery → largest superficial vein of the cubital
fossa
• Loop : brachial artery → largest superficial vein of the cubital fossa
– Brachioaxillary graft
– Upper arm AV fistula (brachial basilic)
Side to side radiocephalic fistula
– Oblique or longitudinal incision is made overlaying the
selected anastomotic site.
– Cephalic vein is located and isolated from the surrounding
subcutanious tissue
– Venous tributaries are ligated and divided to improve
mobility of the vein
– Incision is made in the deep fascia of the forearm and the
radial artery exposed carfully
– Radial artery carefully mobilized , ligating the muscular
branches and isolating it from the surruondhig tissue
– Adequately mobilized length of both vessels are necessary
so that they rest side by side without tension
Side to side brachiocephalic fistula
– When construction of fistula at the wrist is not possible ,
anastomosis of the cephalic vein to the brachial artery
immediately proximal to the cubital fossa will provide
satisfactory access
– A transverse incision is made proximal to the cubital fossa
– The brachial artery is mobilized untill it reaches the
bifurcation at the level of bicipital tendon
– The median nerve lies medial and posterior to the artery
and should be carefully protected
– The anastomosis is similar to the radiocephalic but the
veenotomy and arteriotomy should be limited to about 5 –
7 mm to minimize the incidence of steal syndrome
Side-to-side anastomosis of the brachial artery and the cephalic vein.
Basilic vein – radial artery fistula
– Mobilization of the basilic vein in the forearm and anastomosis
of its end to the radial artery also may be used to provide access
for heamodialysis
– The basilic vein is mobilized along the ulner border of the
forearm to about the middle of the forearm.
– A subcutanious tunnel is prepared between the vein and the
radial artery
– These vessels are then anastomosed attaching the vein end to
either the end or the side of the artery
– This technique of fistula formation may be used in patients who
have an obliterated cephalic vein or distal radial artery
– It is possible to anastomose the basilic vein to the ulner artery,
however if there has been a previous radiocephalic fistula in
that arm , there is a danger that circulation in the hand will be
compromized
 Complications
• Failure:
– The most frequently complication is that of early failure
– Reported incidence of up to 27%
– Such a complication may be a result of :
• Thrombosis: (more in)
– DM
– erythropoietin
• Failure to mature and achieve an adequate flow rate to maintain
dialysis:
– Techniqal problems in constructing the anastomosis
– A sclerotic vein segment in the forearm because of previous venisection
– Inadequate venous size
– Cacification of the arterial wall
 Complications
• Aneurysm:
– Pseudo aneurysm formation may occur at puncture
sites following dialysis
– However , the incidence is much lower than that of
prosthetic grafts
– True aneurysm are much rare but have also been
reported in few occasions in the vein distal to the
anastomosis
– These can be treated with resection and either
• end to end anastomosis
• Placement of short segment graft
 Complications
• Infection:
– Infection of autogenous fistula are rare compared to
prosthetic graft
– They present with:
• Fever
• Erythema
• Tenderness
• And complications (such as thrombosis and aneurysm )
– The most common infecting organism is staph aureus
– Managed by systemic antibiotics , drainage and
revision as necessary
 Complications
• Ischemic changes:
– May occur in around 4% of patients with autogenous fistula
– The incidence is higher in :
• Diabetic patients
• Atherosclerotic patients
• And in anticubital fistulas
– The symptoms may only manifested during dialysis and as such
may be managed by observation and by using low flow rate
– At its worst , gangrene may occur requiring amputation
– To avoid the problem of retrograde flow through the palmar
arch in wrist fistula , ligation of the radial artery distal to the
anastomosiscan be performed . Alternatively an end to end
anastomosis can be constructed
 Complications
• Venous hypertension:
– Another vascular complication is the development of venous
hypertension syndrome , where the hand distal to the fistula
become swollen and uncomfortable with thickning of the skin
and hyperpigmentation
– Venous hypertension may be avoided by forming an end to end
anastomosis
– Or to ligate the enlarged venous tributaries causing the
hypertension of the distal digits , so preserving the fistula
• Cardiovascular complication:
– High output cardiac failure is a rare complication which may
occurs particularly in patients displaying a combination of low
heamatocrit, cardiomyopathy from diabetes and the presence
of high flow fistula