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In an emergency, the AVF should be excluded surgically (Fig. [12](#Fig12){ref-type=”fig”}). If a ruptured AVF is suspected preoperatively by clinical signs or imaging modalities, the catheter must be removed. The AVF should be ligated, as this preserves the fistula and the kidneys of the patient. In a subsequent reoperation or delayed repair, the AVF must be positioned centrally and reconnected to the fistula system. If an arteriovenous shunt is encountered during the procedure, the anastomosis must be occluded and positioned centrally, and the AVF should be ligated \[[@CR32]\]. Occlusion of the shunt can be performed by balloon occlusion with an omental patch or by elective complete ligation \[[@CR27]\]. A concomitant splenorenal shunt, which is often absent after AVF ligation, should be identified and ligated as well \[[@CR33]\]. The right kidney has a longer vascular pedicle and is more easily detachable than the left kidney. Thus, reconstruction can be more difficult for the left kidney. However, it is possible to perform both steps of reconstruction simultaneously. The arteriovenous anastomosis should be performed as described for the right kidney and then the AVF should be ligated. Tissue debris from the distal end of the anastomosis should be flushed out of the system using warm saline and the stump should be ligated. Fig. 12Emergency surgical reconstruction of arteriovenous fistula in the left renal artery after ligation of the fistula in a patient with hemorrhagic shock

Anastomotic stenosis after ligation of an AVF can occur in up to 10% of patients \[[@CR27]\]. Stenosis that occurs within 4 weeks of surgery may respond to balloon angioplasty, while those that develop later can be treated with percutaneous angioplasty, atherectomy, and https://chatbook.pk/upload/files/2022/06/IvvSuLBNZgTc4BnjowFk_07_1c252b7601fa125442a5d1ec0b39cf0c_file.pdf

 

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