What to Expect During a Fistulogram

Many people see vein specialists in Houston for issues like spider veins and venous insufficiency. However, you may be advised to visit a vein treatment center for fistula maintenance if you have a medical condition in which blood needs to be removed through dialysis. Read on to learn about what to expect during a fistulogram procedure for fistula maintenance.

Before Your Fistulogram

A fistulogram is an x-ray procedure that uses contrast dye to examine the blood flow inside your fistula or graft. The purpose of this procedure is to ensure that there is no narrowing or blockages within the fistula. You will be asked not to eat or drink after midnight before your appointment. After checking in, the procedure will be explained by a radiologist, and you will have a chance to ask any questions that you may have. After changing into a hospital gown, you will be given an I.V. for the administration of sedatives during the procedure.

During Your Fistulogram

Once you’re ready for the fistulogram, you’ll be asked to lie on a table that will be surrounded by machines. You may be provided with medications and oxygen to promote your relaxation and comfort. After numbing the area around the fistula, your doctor will place a small catheter in the fistula and inject the contrast dye. If any narrowing is detected, a device will be inserted to stretch the narrowed area. You may be given more medication for this step. After the treatment is complete, 1 or 2 stitches may be placed to close the puncture site, and the catheter will be removed.

After Your Fistulogram

Once the procedure is complete, you can expect to wait in a recovery area for 1 to 2 hours, allowing a nurse to monitor your condition and ensure that the fistula area does not bleed. After this, you will be able to go home or proceed to the dialysis unit. You will need to have someone drive you home or to your dialysis appointment following your fistulogram.

Why Your Fistula or Graft Needs Regular Attention

For people on hemodialysis, the fistula or graft in the arm is a lifeline. An arteriovenous (AV) fistula is a direct connection between an artery and a vein, created surgically so the vein enlarges and can handle the high flow dialysis needs. An AV graft uses a soft synthetic tube to connect the artery and vein. Both are punctured with needles several times a week, and both are under constant high pressure and turbulent flow.

That turbulence makes the vein lining thicken over time, a process called neointimal hyperplasia. The result is a gradual narrowing, known as a stenosis, most often where the vein joins the artery, in the outflow vein, or in the central veins near the chest. A narrowing slows flow, makes dialysis less effective and, if left alone, can let a clot form and shut the access down completely. A fistulogram is how we find and fix these problems before that happens.

Warning Signs That a Fistulogram May Be Needed

Your dialysis team is trained to notice early changes, and they will often be the ones who refer you. Common reasons include:

• A weaker thrill (the buzzing feeling over the access) or a change in the whooshing sound, called the bruit
• A pulse over the access that feels unusually hard and pounding
• High venous pressures or low blood flow during dialysis
• Prolonged bleeding from needle sites after dialysis
• Difficulty placing needles or frequent clotting of the circuit
• Swelling of the arm, hand, neck or face on the side of the access
• Falling dialysis adequacy numbers despite unchanged treatment time
• A new fistula that is not maturing as expected

Swelling of the whole arm, or of the face and neck, often points to a narrowing in the central veins that drain the arm, which can only be properly seen and treated with a catheter study.

A clotted access is time-sensitive. When it is declotted promptly, it can often be saved and you may avoid needing a temporary dialysis catheter.

Preparing for Your Fistulogram: A Practical Checklist

Good preparation makes the day run smoothly and keeps the procedure safe. In addition to fasting instructions, our team will usually go over the following with you a day or two beforehand:

• Medication list. Bring a current list, including blood thinners such as warfarin, apixaban or clopidogrel. Some may be paused or continued depending on the procedure, but never stop one without instructions.
• Diabetes medicines. If you are fasting, your insulin or tablets may need adjusting to avoid low blood sugar. Ask us or your doctor for specific guidance.
• Dialysis timing. Tell us your dialysis days and times. Many patients have the fistulogram on a non-dialysis day or just before a session, so potassium and fluid levels are in a safe range.
• Contrast allergy. Let us know about any prior reaction so pre-medication can be arranged.
• Clothing and a driver. Wear a loose short-sleeved top, leave jewelry at home, and arrange for an adult to drive you afterward because of the sedation.

Fistulogram vs Other Access Procedures

Several procedures are used to look after dialysis access. They are often combined in a single session depending on what the images show.

How We Evaluate a Dialysis Access Problem

Dialysis access care is an interventional radiology service at our practice. Before any procedure, we want to understand your access and your history so the study is focused and safe.

1. Focused history. We review when and how your fistula or graft was created, past procedures on it, recent dialysis numbers and the specific problem your dialysis unit has noticed. We also review blood thinners, allergies to contrast dye and your dialysis schedule.
2. Examination of the access. We feel the thrill and pulse along the access, listen to the bruit, raise the arm to see whether the fistula collapses as it should, and check for swelling, aneurysms or skin problems over the needle sites.
3. Ultrasound when helpful. A duplex ultrasound can measure flow, look at fistula size and depth, and show narrowing, which is especially useful for new fistulas that are not maturing.
4. A clear plan. We explain whether a fistulogram is needed, what treatment might be done during it, and how the timing will fit around your dialysis days.

You can read more on our dialysis fistula evaluation page.

Is a Fistulogram Painful?

Most patients are surprised by how manageable it is. The skin is numbed with local anesthetic before the small needle and sheath are placed, so you mainly feel pressure. Many patients receive light IV sedation to stay relaxed. When contrast is injected, some people feel a brief warm sensation.

The most noticeable part for many patients is the balloon angioplasty, if one is needed. When the balloon is inflated to open a tight narrowing, it can cause a deep ache in the arm for a short time. We let you know before inflating, can give extra pain medicine through your IV, and the discomfort fades once the balloon is deflated.

Contrast Dye and Your Kidneys

Patients who still make some urine, or who are early on dialysis, often ask whether the contrast will harm their remaining kidney function. Residual function is valuable, and we take that question seriously. The amount of contrast used in a fistulogram is usually small, and it is removed at your next dialysis session. If you have not yet started dialysis, or you have meaningful residual function, we discuss the risks and benefits with you and your nephrologist and can adjust the technique to use less contrast.

If you have had an allergic reaction to contrast before, tell us in advance. Pre-medication can be given to reduce the chance of a reaction.

Recovery and Caring for Your Access Afterward

In addition to the recovery time described above, a few practical points help your access heal and keep working well:

• Keep the puncture site dressing clean and dry for the time your team advises
• Check the thrill over your access each day, ideally morning and evening, and report any change promptly
• Avoid blood pressure cuffs, blood draws, IVs, tight sleeves, watches or jewelry on the access arm
• Do not sleep on the access arm or carry heavy bags over it
• Some bruising and mild soreness are normal for a few days
• Let your dialysis nurses know you had a procedure so they can adjust needle placement if needed

After an angioplasty, many patients notice that dialysis runs more smoothly, with better flow and less bleeding after needles are removed.

How Often Is a Fistulogram Needed?

There is no fixed schedule. Some fistulas work for years without needing any treatment, while others develop narrowing that returns and needs angioplasty every few months. Grafts generally need more frequent maintenance than fistulas. Rather than treating on a calendar, most access teams act when the dialysis numbers or the physical exam suggest a problem is developing. Close communication between your dialysis unit, your nephrologist and our interventional team is the best way to keep the access working and avoid emergencies.

When the narrowing keeps coming back

If a stenosis recurs quickly after angioplasty, there are other options. A covered stent or stent graft may keep the segment open longer in selected cases, and occasionally a surgical revision is the better choice. We discuss these options openly with you and your surgeon and nephrologist so the access lasts as long as possible.

Protecting your veins for future access

Every dialysis patient has a limited number of veins suitable for access, so protecting them matters for the long term. Ask that blood draws and IVs be placed in the hand or in the arm without the access whenever possible, and remind hospital staff that you are a dialysis patient before any line is placed. Avoiding unnecessary catheters in the large neck and chest veins also lowers the chance of central vein narrowing later on.

Getting Dialysis Access Care in Houston

If your dialysis unit has flagged a problem with your fistula or graft, or you have noticed changes yourself, the access should be evaluated promptly. Our team, led by Dr. Syed Raza, a fellowship-trained interventional radiologist and former Chief of Interventional Radiology at UTMB Galveston and Memorial Hermann Memorial City, performs fistulograms and access interventions using image guidance and other ultrasound-guided procedures. Our Houston interventional radiology and vein clinic works directly with dialysis units across Houston and Katy to schedule around your treatment days, and most insurance plans, including Medicare, are accepted.

Frequently Asked Questions

How long does a fistulogram take?

A diagnostic fistulogram may take about 30 minutes. If angioplasty, a stent or clot removal is needed, the procedure can take up to 90 minutes or longer. Plan to spend a few hours at the facility including preparation and recovery.

Can I have dialysis on the same day as a fistulogram?

Often, yes. In many cases the access can be used for dialysis the same day after the procedure, and some patients go straight from recovery to their dialysis unit. Your team will tell you if your situation requires waiting.

What is the difference between a fistulogram and an angioplasty?

A fistulogram is the imaging study that shows the inside of the fistula or graft with contrast dye. Angioplasty is the treatment, a balloon that opens any narrowing the fistulogram finds. The two are usually done together in one session.

How do I know if my fistula is clotted?

The most common sign is that you can no longer feel the buzzing thrill or hear the whooshing bruit over the access. The access may also feel hard or painful. Contact your dialysis unit or access team right away, because a clotted access can often be reopened if treated quickly.

Are there risks to a fistulogram?

Fistulograms are generally safe. Possible risks include bruising or bleeding at the puncture site, a reaction to contrast dye, and, rarely, injury to the vein during angioplasty that may need a stent. Your doctor will discuss these with you beforehand.

Who performs a fistulogram?

Fistulograms are usually performed by interventional radiologists or other vascular specialists trained in image-guided procedures. They work closely with your nephrologist and dialysis unit to keep your access working.

Trusted Health Resources

1. Hemodialysis, National Institute of Diabetes and Digestive and Kidney Diseases (NIH)