Fistulogram

A fistulogram is an X-ray picture of your dialysis access. We place a tiny tube into your fistula or graft and inject contrast dye, a liquid that shows up on X-ray. The dye lets us see the whole path of blood, from the artery connection in your arm to the large veins in your chest.

The most common finding is a stenosis, a segment where scar tissue has built up inside the vein and made it narrow. If we find one, we treat it in the same visit with balloon angioplasty, which means inflating a small balloon inside the narrowing to stretch it open. So a fistulogram is both a test and a treatment.

On the fistulogram, the access fills with dark contrast like a river. A stenosis looks like a tight waist in the river, and after the balloon the waist is gone and the dye flows quickly to the chest.

Fistulas and grafts carry very high blood flow. Over months to years, the vein wall reacts by growing scar tissue, most often near the artery connection, where a graft joins the vein, or in the veins near the shoulder and chest. A narrowing slowly reduces flow, makes dialysis less effective, and can lead to a clot.

If your access has no thrill at all, it has probably clotted. That needs a declot procedure, which includes a fistulogram. See clotted dialysis access.

Balloon angioplasty is the first treatment for most narrowings. Sometimes the vein springs back after the balloon, or the narrowing returns quickly. In that case we may place a stent, a small tube made of metal mesh, or a stent graft, a stent covered with fabric, to hold the vein open. Stent grafts are often used where a graft joins the vein, because they tend to keep that area open longer.

Narrowings often come back, because the same flow that makes an access work keeps stimulating scar tissue. Many people need a repeat balloon treatment every few months to a year. That is normal and does not mean the first treatment failed. If an area keeps narrowing quickly, we discuss a stent or surgery with your nephrologist and vascular surgeon.

For more on the day itself, see before your procedure and sedation.

The procedure is done at El Camino Hospital in an interventional radiology suite. A team of nurses, a radiology technologist and your interventional radiologist care for you. You lie on your back with your arm stretched out on an arm board, and we monitor your heart rate, blood pressure and oxygen the whole time.

1. 1
   Relax and numb

   A nurse gives you moderate sedation, sometimes called twilight sleep, through an IV. You are relaxed and drowsy but breathing on your own. We clean your arm and numb a small spot over the access with local anesthetic, which stings for a few seconds.

2. 2
   Map the access

   Using ultrasound, we place a small needle and then a thin plastic sheath into the access. We inject contrast dye and take X-ray pictures from the artery connection to the veins in your chest.

3. 3
   Open the narrowing

   If there is a stenosis, we pass a balloon to that spot and inflate it for a minute or two. You may feel a deep ache while the balloon is inflated, and we give you more medicine if needed. If the vein recoils, we may place a stent.

4. 4
   Check and close

   We take more pictures to confirm good flow and check that the thrill is strong. We remove the sheath and close the puncture with a small stitch, a plug or pressure, then apply a small dressing or skin glue.

Most fistulograms take about 30–60 minutes. If we find a small clot, we can often remove it during the same procedure.

1. First hour
   You rest in recovery while nurses check your puncture site, pulse and blood pressure. You can eat and drink, and your family can join you.
2. Rest of the day
   Go home with a driver and take it easy. No driving, alcohol or important decisions until the next day, because of the sedation. You can usually shower the same evening.
3. Next dialysis
   In most cases your access can be used right away. If you are due for dialysis the same day, your nephrologist may arrange it at the hospital. We will tell you if you need to wait.
4. Days 1–3
   Mild soreness and bruising are normal; the bruise may darken before it fades. Use acetaminophen (Tylenol) if needed and avoid ibuprofen and naproxen.
5. First week
   Avoid heavy lifting, strenuous exercise and contact sports with that arm. Check your thrill every day.

If the puncture site starts to bleed, stay calm. Press firmly on the spot with one or two fingers for a full 15 minutes without peeking. Almost all bleeding stops this way. Then call us at 650-404-8445. If it does not stop with firm pressure, keep pressing and call 911.

Most narrowings open well with a balloon, and dialysis usually improves right away, with better flow and shorter bleeding times. How long the result lasts varies from person to person; the narrowing often returns within months, which is why daily thrill checks and regular monitoring at dialysis matter.

When I read a fistulogram, I do not stop at the spot where the needles go. I follow the dye all the way into the chest, because a narrowing near the heart can cause arm swelling and poor flow even when the arm looks fine. I tell patients that needing a balloon again in six months is not a failure; it is maintenance, like servicing a car, and it keeps a good access going for years.

Fabio Komlos, MD, interventional radiologist · About Dr. Fabio Komlos