Fistulogram/ Fistuloplasty - A guide for patients

Introduction

This leaflet is designed for patients who have been advised to have a fistulogram or fistuloplasty.

What is a fistulogram/fistuloplasty?

• A fistulogram is a procedure where x-ray pictures are taken of your fistula to look for any narrowing of the vessels.
• Normally vessels do not show up on an ordinary x-ray so a dye, called contrast medium, is injected into the vessels through a fine plastic tube called a catheter to make them visible.
• X-rays are taken during the procedure. These images will assist the doctors performing the procedure to make a decision on whether any further treatment is needed to improve the fistula function.
• A fistulopasty is when a balloon is introduced into the area of narrowing inside the fistula. This balloon is inflated from outside the body momentarily and then deflated to improve the narrowing.
• A completion fistulogram is then carried out to check the result.

Why do I need this procedure?

Occasionally, the blood vessels that make up a fistula can develop a narrowing which is diagnosed with a fistulogram. A fistuloplasty may be needed if your doctor has identified that there is a narrowing or blockage in one of your blood vessels that is causing you a problem.

Who has made the decision for me to have this procedure?

The Consultant in charge of your case and the Interventional Radiologist performing the fistulogram/fistuloplasty will have discussed your case and come to the conclusion that this is the best way of treating your condition.

You will have the opportunity for your opinion to be taken into account, and if after discussion with your doctors, you do not want the procedure carried out, you can decide against it.

Who will be performing the procedure and other staff you are likely to meet?

• A specially trained doctor called an Interventional Radiologist will be performing your procedure.
• Radiologists have special expertise in using x-ray equipment and in interpreting the images produced, as well as performing minimally invasive procedures.
• They will look at these images whilst carrying out the procedure.
• The Interventional Radiologist will be assisted by a radiographer and nurses and/or other Radiology doctors or trainees.

Where will the procedure take place?

You will be taken to the Interventional Radiology Department.

What happens before my procedure?

• You may be admitted to hospital on the day of, or the night before the procedure.
• A doctor will take a medical history from you.
• You may have a small needle put into a vein in your arm for painkillers to be given if necessary.
• Standard blood tests may be carried out.
• You may eat a light meal and drink as normal unless otherwise informed – in which case, you may be fasting for 4-6 hours prior.
• You may be given antibiotics or other pre-medication on the morning of the procedure if required.
• If you have any allergies you must let your doctor know and a red allergy band will be attached to your wrist.
• If you take any medications to thin the blood (anticoagulants or antiplatelets) please let us know beforehand, as these will need to be stopped a certain length of time before the procedure.
  • Examples include: warfarin, dalteparin, enoxaparin, tinzaparin, dabigatran, rivaroxaban, apixaban, clopidogrel, ticagrelor.
  • Low dose aspirin (75mg) is safe to continue.
  • Please discuss with a doctor before stopping any medicines, as sometimes other treatment will need to be given.
• If you have previously reacted to intravenous contrast medium (the dye used for CT scans), you must also tell your doctor about this.

What happens during the procedure?

• You will get dressed into a hospital gown.
• You will lie on the x-ray table, generally flat on your back.
• You will have a monitoring device attached to your finger and will have a blood pressure cuff placed around your arm.
• The procedure is performed under sterile conditions and the radiologist and scrub nurse will wear sterile theatre gowns and operating gloves.
• Local anaesthetic will be injected into the skin. A needle, often followed by a fine plastic tube, will then be placed in the fistula and dye injected.
• Occasionally, it may be necessary to place a fine plastic tube in the vein in your groin as all the veins inside your body are connected and treatment is sometimes carried out via the groin vein, as this may be a safer option than directly through the fistula.
• Small catheters (plastic tubes) will then be guided into the veins that are blocked or narrowed.
• When pictures need to be taken some iodine dye will be injected; you will be asked to hold your breath for a short time at these points. You may feel a hot feeling from the dye, and it can make your bladder feel full.
• If a vessel narrowing or blockage is identified a balloon is inflated to open up the vessel (venoplasty). This may be done more than once in order to open up the vessel sufficiently.
• Once the procedure is completed you will be moved back onto your hospital bed.
• The tube in the fistula will then be removed, and pressure applied on the site for several minutes.

Will the procedure hurt?

• Some discomfort may be felt in the skin and deeper tissues during injection of the local anaesthetic.
• You may feel a warm sensation for a few seconds when the x-ray dye is injected and some people report a metallic taste in the mouth. You may also feel like you are passing urine; this is normal.
• The fistulogram is not painful although you may feel a little discomfort when the balloon is being inflated during the fistuloplasty. There will be a nurse, or another member of the clinical staff, in the room looking after you.

How long does the procedure take?

Every patient’s situation is different, and it is not always easy to predict how complex or how straightforward the procedure will be. Generally, the procedure will last approximately one hour.

What will happen after the procedure?

• You will be taken back to your ward for observations and a period of bed rest, prior to being sent home. You may also stay for further treatment or investigations.
• Nursing staff will carry out routine observations including taking your pulse and blood pressure readings and will also check the treatment site.
• If you experience pain, sickness, abnormal swellings or are generally feeling unwell, please let the nursing staff know.
• You can usually go home 30 minutes after a fistulogram but will need to stay in hospital for a few hours following fistuloplasty.

What are the benefits and possible risks of the procedure?

Benefits

• The procedure should allow for any problems with your fistula to be identified and treated if necessary.

Risks

Fistulograms are a very safe procedure but there are some risks and complications that can occur.

• Very occasionally, a small bruise can appear at the site of needle puncture.
• Less commonly, ongoing bleeding in this area leads to a short inpatient stay (once or twice in every hundred).
• Very rarely damage to the fistula can occur that may require further treatment by the interventional radiologist or a small operation.
• The risk of infection is very low.

Fistuloplasty

• There is a small risk of failure of treatment.
• Sometimes the narrowing in a fistula does not respond well to the fistuloplasty and requires a stent.
• The risk of bleeding is slightly higher than for fistulogram (about three-in-100 chance).
• There is a small risk that the treatment may damage or even rupture the fistula/vein. If this were to happen, the fistula may fail and could not be used for dialysis. A small operation may be required at the time but more likely a line would be placed and a new fistula fashioned.
• When considering this risk, it is important to bear in mind that leaving a narrowing in a fistula or vein, without treatment it is likely your fistula would ultimately fail.

Radiation

• You have been referred for an Interventional Radiology procedure to help deliver your treatment. A specialist in radiology agrees that this is the best procedure to treat your clinical condition and that the benefit of the examination is greater than the risk.
• The x-ray involves a dose of ionising radiation equivalent to a few months or years of natural background radiation which we are all exposed to every day.
• Ionising radiation can cause cell damage that may turn cancerous, however the risk of this happening from your examination is considered low.
• Depending on the length of the procedure there may also be a small risk of an excess radiation dose to the skin leading to short term and long-term effects (e.g. reddening of the skin and burns).
• If this happens as a result of this procedure, you will receive further advice following the procedure. The dose delivered will be kept as low as is practicable.
• For further information please see the information on our webpage.

Accessibility requirements

If you require support for your appointment, e.g. if you find it hard to hear, see or be understood by others, please let the receptionist or healthcare professional know on arrival or

• contact us by email

or

• Telephone: 01223 256998

Pregnancy status

We have a legal responsibility to enquire if you are pregnant. Any patient aged between 12-55 years will be asked if there is a possibility they could be pregnant. This is important for us to know before you have your examination involving ionising radiation.

You can discuss this with a healthcare professional in private if you wish.

Medication

Bring all of your medicines (including inhalers, injections, creams, eye drops or patches) and a current repeat prescription from your GP.

Can I bring someone with me?

Those accompanying you may be required to stay out of the examination room during the procedure and remain in the waiting area.

Childcare whilst in the department

Staff are unable to look after or supervise children whilst your procedure is taking place. Please make alternative arrangements for the care of your children whilst you attend for your procedure. If you attend an appointment with children with no one to look after them whilst you have your procedure, then your appointment will unfortunately have to be cancelled and rescheduled.

Personal belongings

Patients are advised to bring minimal belongings and not to bring valuable items. Any valuable belongings (mobile phone, wallet etc.) will go with the patient while having their procedure and can be secured in a locked box/safe.

How, when and by whom will my results be communicated?

Imaging examinations are reported in order of clinical priority to ensure those with the highest urgency are reported first.

Your referring team or clinician will be responsible for communicating reports back to you.

Test results are made available via MyChart but there is 3-week delay from when an examination has been reported to when it is available on MyChart, in order to allow time for your clinical team to be able to see and action the results prior to them being released to the individual patient.

Contacts/Further information

Please call the Radiology Day Unit and speak to the Imaging Nurses, on telephone number 01223 254639 if you have any questions or concerns about this procedure.

Some of your questions about the procedure should have been answered by this leaflet, but remember this is only a starting point for discussion about your treatment with the doctors looking after you and you will be able to discuss any questions you have with them.

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Question, concern or complaint?

Firstly speak to your nurse, doctor or other staff member as soon as you can so they can do their best to put things right straightaway.

If you don’t feel able to speak directly to the people caring for you, contact the patient advice and liaison service (PALS). Please call 01223 216756 9am to 4pm Monday to Friday, via email, or via a form available via link on the CUH PALS webpage.

PALS is open every weekday, and you can leave a message in the evenings and weekends.

MyChart

We would encourage you to sign up for MyChart. This is the electronic patient portal at Cambridge University Hospitals that enables patients to securely access parts of their health record held within the hospital’s electronic patient record system (Epic). It is available via your home computer or mobile device.

More information is available on our website: MyChart

This document has been adapted from one prepared by the British Society of Interventional Radiology (BSIR).