Left Brachiocephalic AV Fistula Creation Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Open/Laproscopic Orchidopexy ± Orchidectomy

1. Patient Identification

I, ______________________________ (patient/next of kin/legal guardian), aged ____ years, in my full senses, voluntarily authorize and give my complete consent for performance of the following procedure(s)/operation(s)/treatment(s):

Procedure: _______________________________
Diagnosis: ________________________________
Major illness & comorbidities: ________________________________

2. Authorization for Procedure

I authorize Dr. __________________ to perform the above procedure, along with such assistants and associates as may be selected by him/her.

I understand that members of the surgical team, including residents or trainees under appropriate supervision, may perform parts of the procedure according to their training and competence.

3. Nature of Procedure

A Left Brachiocephalic AV Fistula is created by surgically connecting the brachial artery to the cephalic vein at the elbow/upper forearm.

This creates a high-flow vascular connection that allows the cephalic vein to mature and subsequently be accessed for haemodialysis.

The procedure may be performed under:

  • Local anaesthesia
  • Regional anaesthesia
  • General anaesthesia

depending on clinical need and the decision of the surgeon and anaesthetist.

4. Benefits and Indications

The procedure may be performed to create permanent vascular access for haemodialysis in patients with kidney failure.

It may be considered when the patient’s vascular anatomy is suitable for a brachiocephalic fistula.

The intended benefits include:

  • Creation of long-term vascular access for haemodialysis.
  • Better long-term dialysis access compared with central venous catheters.
  • Lower infection risk compared with dialysis catheters.
  • Improved dialysis adequacy.
  • Improved vascular-access durability.

However, successful maturation and long-term patency cannot be guaranteed.

5. Risks and Complications

  • Intra-operative
    • Bleeding: 2–10%
    • Blood transfusion may rarely be required: <1–2%
    • Injury to artery or vein: 1–5%
    • Arterial spasm or poor blood flow causing technical difficulty: 2–5%
    • Nerve injury/numbness around the operative site: 1–3%
    • Change in the planned site or type of fistula depending on vessel quality: 5–15%
    • Failure to create a usable fistula during surgery: 2–10%
    • Infection: <2–5%
    • Allergic or anaesthesia-related complications: <1–2%
    • Need for ICU care: rare, <1%
    • Rare risk of death: <1%
  • Post-operative
    • Pain, swelling or bruising at the operative site.
    • Wound infection: 2–5%
    • Haematoma/seroma: 2–10%
    • Thrombosis/clotting of the fistula: 5–20%
    • Failure of fistula maturation: 10–30%
    • Poor flow/non-functioning fistula requiring further procedure: 10–30%
    • Steal syndrome: 2–8%
    • Hand oedema/venous hypertension: 2–10%
    • Pseudoaneurysm/aneurysmal dilatation: 1–5%
    • Stenosis requiring angioplasty or revision: 10–30%
    • High-flow fistula/cardiac strain: rare, 1–5%
    • Need for reoperation/revision/alternate access: 10–30%
    • Scarring or cosmetic deformity. Rare distal ischaemia or tissue loss: <1%
  • Fistula Maturation and Long Term Function
    • The fistula will not usually be usable immediately after surgery.
    • It requires several weeks to mature before it can be used for dialysis.
    • Follow-up examination and ultrasound may be required.
    • Angioplasty, surgical revision or other procedures may be required if maturation or blood flow is inadequate.
    • Even after initially successful surgery, the fistula may clot, fail or stop functioning in the future.
    • If the fistula is unsuccessful, an alternative dialysis-access procedure may be required.

6. Postoperative Course

I understand that:

  • Keeping the operated limb elevated.
  • Avoiding blood-pressure measurement on the fistula arm.
  • Avoiding venepuncture/blood sampling from the fistula arm.
  • Monitoring the fistula for a thrill/bruit.
  • Watching for signs of infection.
  • Watching for symptoms of reduced blood supply to the hand, including pain, coldness, weakness or colour change.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Conservative management, if dialysis is not yet required.
  • Temporary or tunnelled central venous catheter.
  • AV graft.
  • Alternative AV fistula, such as:
    • Radio-cephalic AV fistula
    • Brachiobasilic AV fistula
  • The choice depends on vein quality, artery size, urgency of dialysis and overall medical condition.

8. Anaesthesia and Pain Management

I understand the risks associated with local, regional, or general anaesthesia.

Pain management options have been explained.

9. Photography / Data Use

I consent to:

☐ Medical photography/video for academic purposes

☐ Use of anonymized clinical data

10. Intraoperative Decision Consent

I authorize the surgeon to perform additional procedures considered necessary if unexpected findings arise during surgery.

11. Team-Based Care

I understand that supervised residents, fellows, or assistants may participate.

12. Patient Statement

I confirm that:

  • The nature of surgery has been explained.
  • Risks, benefits, and alternatives have been explained.
  • My questions have been answered satisfactorily.
  • I voluntarily consent.

Patient to write in own handwriting:

“I have understood the procedure, risks, benefits and alternatives explained to me in a language I understand.”

Signatures

Patient Name & Signature: ______________________________________

Date: ____________________ Time: ____________________

Doctor Name & Signature: ______________________________________

Date: ____________________ Time: ____________________

Witness Name & Signature: ____________________________________

Contact No.: ______________________________

ATTENDANT CONSENT (If applicable)

Reason patient unable to consent:

Attendant Name: __________________________________________

Relationship: _____________________________________________

Signature: ________________________________________________

Contact No.: ______________________________________________

INTERPRETER STATEMENT (If applicable)

I confirm an accurate explanation in understandable language.

Name: _________________________________________________

Signature: ______________________________________________

Contact: ________________________________________________

HIGH-RISK CONSENT (If applicable)

High-risk factors explained due to:

Patient Signature: ________________________________________

Doctor Signature: _________________________________________

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