Frequently Asked Questions about Dialysis Access Surgery | BIDMC of Boston (2024)

What is dialysis access surgery?

Dialysis, either hemodialysis or peritoneal dialysis, is a life-savingprocedure that replaces kidney function when the organs fail. In order tobe treated with dialysis, physicians must establish a connection betweenthe dialysis equipment and the patient's bloodstream. Dialysis accesssurgery creates the vascular opening so a needle can be inserted forhemodialysis or an abdominal catheter inserted for peritoneal dialysis.

There are several ways to establish dialysis access. Your nephrologist(kidney doctor) and surgeon will work with you to decide which type ofaccess will provide you with the best long-term dialysis.

Who performs the dialysis access procedure?

Establishing dialysis access is an invasive (surgical) procedure that canbe performed by nephrologists, interventional radiologists and surgeons. Ateam effort helps ensure excellent patient service, care and long-termresults. The dialysis access center at BIDMC is staffed with leadingnephrologists, interventional radiologists and transplant surgeons in theBoston community. The team also consists of a dialysis access nursecoordinator and social workers. We meet regularly to ensure that youreceive the best care each specialty has to offer.

What type of dialysis access procedure is necessary for hemodialysis?

Hemodialysis circulates blood through a machine outside of your body toremove toxins and excess fluid and to correct electrolytes like potassium,sodium, phosphate and calcium, to name a few. The machine then pumps thecleansed blood back into your body. The blood leaves and returns to thebody through a catheter, a long piece of silicone tubing placed in theneck, chest or leg. A catheter is used to establish quick vascular(bloodstream) access if you need to begin dialysis therapy immediately. Ordialysis access nurses can access the bloodstream by placing two needlesinto a fistula or a graft that has been previously created for thispurpose.

How are catheters placed?

Catheters come in two varieties, temporary and permanent. Temporarycatheters penetrate the skin and directly enter the venous system.Permanent catheters also penetrate the skin, but are then tunneled underthe skin for several inches before they finally enter the venous system.Tunneling the catheter reduces the risk of infection.

Any medical professional can place a temporary catheter using a localanesthetic and minimal sedation to help with minor discomfort. However forplacement of permanent catheters, a surgeon in the operating room, or aninterventional radiologist in the interventional suite is necessary. Duringthe procedure, physicians use fluoroscopy (continuous X-rays) to be surethe catheter is positioned correctly. Permanent catheters require a minorprocedure for removal whereas temporary catheters can simply be pulled out.

Are catheters safe for long-term use?

Prolonged catheter access can lead to multiple complications, the mostcommon of which is infection. Even with excellent placement technique,bacteria can enter the bloodstream directly through the catheter duringdialysis. Bacteria from the skin can also move down the catheter and enterthe bloodstream. With catheter infection people develop high fevers andchills and need prompt treatment. Generally physicians must remove thecatheter so the body can fight the infection.

Another possible complication from long-term catheter use is damage to themain chest vessels, which can lead to stenosis (narrowing) or thrombosis(clotting) of the veins. This type of damage is usually permanent and thevessel - as well as the arm on the side of the vessel - may no longer beuseable for dialysis access.

Because of these potential complications, physicians make every effort toavoid prolonged catheter use.

What is an AV fistula?

The best way to establish long-term hemodialysis access is to construct anarteriovenous (AV) fistula. An AV fistula is a surgically placed "shunt";that is, an artery is directly sutured to a vein. An artery is ahigh-pressure vessel that carries blood away from the heart and deliversnutrients and oxygen to the tissues. A vein is a low-pressure vessel thatreturns blood back to the heart to begin the process all over again.

When an artery and a vein are sewn together, the high-pressure blood doesnot reach the tissues but is diverted instead into the vein and back to theheart. Over time the vein will dilate, carry more blood and becomestronger, a process that is often called maturation. At maturation, nursescan easily access the vein with needles for dialysis therapy.

Where are AV fistulas located and how long do they last?

Surgeons can create an AV fistula in your wrist, forearm, inner elbow orupper arm. When properly constructed, and with satisfactory maturation, anAV fistula can function for many years.

How is the AV fistula procedure performed?

A surgeon usually performs the procedure in the operating room. You receivea local anesthetic (numbing medicine) at the proposed site along with IVsedation to relax you. Discomfort is minimal and you may even fall asleepduring the 1 to 2 hour-long procedure. The surgical incision is usuallyonly 2 to 4 inches long. Generally you are able to return home later thatsame day. The fistula usually requires from 8 to 12 weeks for the veins todilate prior to initial use.

Despite excellent technique, some patients may suffer complications fromthe AV fistula procedure. Infection, bleeding, arm swelling and/or tinglingin the fingers may occur postoperatively. An unusual, but serious,complication can occur when the arterial blood that is supposed to reachthe hand is redirected through the fistula. Sometimes the fistula functionsso well that not enough blood reaches the hand causing ischemia (lack ofoxygen). This condition is called "steal" and usually requires surgicalprocedure to establish a new access at a different site.

Can anyone have an AV fistula?

Unfortunately not every patient is suitable for an AV fistula. Numerousneedle sticks for IV fluids, blood work and/or medicines can damage veinsover time, creating scar tissue, which can make creation of an AV fistulaimpossible. If the veins are damaged or too small, the AV fistula will notmature, or worse yet, clot. In this situation, the dialysis access teamrecommends other options that may include another fistula at a differentsite, catheter placement or an arteriovenous graft.

What is an arteriovenous graft?

An arteriovenous graft is another form of dialysis access, which can beused when people do not have satisfactory veins for an AV fistula. In thisprocedure, surgeons connect an artery and a large vein in your elbow orarmpit using a graft made of synthetic fabric that is woven to create awatertight tube. The graft is frequently used to repair blood vessels orperform blood vessel bypass when blockages occur, and also works very wellto establish dialysis access.

How is the AV graft created?

Creating an AV graft is a surgical procedure, which requires a smallincision at the proposed site. Surgeons sew the graft to an artery andtunnel it, just under the skin, creating a loop back to the startingincision where it is then sewn to a vein. The long loop gives the dialysisnurses space to access the graft. AV grafts can be safely used in about twoweeks, as no maturation of the vessels is necessary. Grafts have a lifespanof approximately 2 to 3 years but can often last longer. However, AV graftscan be more troublesome than AV fistulas. Blood is more likely to clot ingrafts because they are made of prosthetic (foreign) material. When thishappens, interventional procedures can remove the clot and restore bloodflow for dialysis.

Complications related to AV grafts are similar to those with AV fistulas:bleeding, thrombosis (clotting), steal and because of the prosthetic natureof the graft, infection. Infected grafts must be removed immediately and anew access site developed once the infection clears.

What type of dialysis access procedure is necessary for peritonealdialysis?

Surgeons must place a long silicone-based tube called a Tenckhoff catheterinto the abdomen before peritoneal dialysis can begin. The surgeon in theoperating room positions the tube using a local anesthetic and IV sedation.Making a small incision in your abdomen, the surgeon advances the tube deepinto the lower part of your peritoneal cavity (the membrane lining theinside of the abdomen), tunnels the tube under the skin for several inches,brings the tube up through the skin at a different location, and thensurgically closes the initial incision. A sterile dressing covers thecatheter that remains outside of the body.

Tunneling the catheter reduces the likelihood of infection in theperitoneal cavity. You may be allowed to go home the same day of surgery.Peritoneal dialysis can begin when the incisions heal, usually about 2 to 4weeks after the access surgery.

What types of complications are possible from the Tenckhoff catheter?

Complications related to catheter placement may include bleeding and damageto large or small intestines or abdominal blood vessels. Although unusual,these issues could require additional corrective surgery. Once peritonealdialysis begins, complications related to repeated use of the catheterinclude peritonitis, which is an infection of the peritoneal cavity.Peritonitis, which can be quite serious, is usually associated withabdominal pain, fevers and cloudy peritoneal dialysis solution. If theinfection does not respond to antibiotic treatment, then it may benecessary to remove the catheter.

When should dialysis access surgery take place?

The best approach is to undergo dialysis access surgery well beforedialysis therapy needs to begin, which will give the access site time tomature and avoid the use of temporary catheters. You may need a temporarycatheter while you are waiting for your permanent AV fistula or AV graft toheal.

How does the dialysis access team evaluate individuals for long-termsuccess?

Our team, which includes a nephrologist, interventional radiologist,surgeon and dialysis access coordinator, perform an extensive physical examto identify satisfactory vessels to construct the AV fistula or graft. Wemay request additional studies such as ultrasounds or even dye studies ofthe blood vessels in your arms and legs. After we decide on the appropriatetype of access, we select the location. Typically surgeons constructhemodialysis access in the forearm of your non-dominant hand. If this siteis not suitable then we may choose to use the forearm of the dominant handor the upper arm of your non-dominant hand, above the elbow.

Whom do I call for more information?

For more information about the Transplant Institute at Beth IsraelDeaconess Medical Center, please call 617-632-9700.

Frequently Asked Questions about Dialysis Access Surgery | BIDMC of Boston (2024)


What are the two most common complications of a dialysis graft access? ›

Complications related to AV grafts are similar to those with AV fistulas: bleeding, thrombosis (clotting), steal and because of the prosthetic nature of the graft, infection. Infected grafts must be removed immediately and a new access site developed once the infection clears.

What is the rule of 6 for dialysis access? ›

Objective: The Rules of 6 (flow volume >600 mL/min, vein diameter >6 mm, vein depth <6 mm) are widely used to determine when an arteriovenous fistula (AVF) will support dialysis. Thus, we tested the utility of the Rules of 6 in clinical practice.

What is the most common complication of AV fistula? ›

  • Heart failure. This is the most serious complication of large arteriovenous fistulas. ...
  • Blood clots. An arteriovenous fistula in the legs can cause blood clots to form. ...
  • Leg pain due to lack of blood flow (claudication). ...
  • Internal bleeding.

What are the restrictions after fistula surgery? ›

Activity After Hemodialysis Fistula or Graft Access Surgery

Please avoid heavy physical exercise or exertion for two weeks. Please do not drive until you have stopped taking your prescription pain medication. You may go back to routine daily activities as soon as you like - as long as they do not involve heavy lifting.

What is the biggest problem with a graft for dialysis? ›

Although AV fistulas are preferred for hemodialysis, AV grafts are sometimes necessary but have higher failure rates. Failure can be related to stenotic lesions affecting the feeding arteries, within the graft or in the draining veins, including the central veins.

How long does it take for a dialysis graft to heal? ›

Graft: An artery and a vein in your arm are joined by a U-shaped plastic tube under the skin. Needles are inserted into the graft when you have a dialysis. A graft can be ready to use in 2 to 4 weeks.

What is the maximum blood flow rate for a dialysis fistula? ›

"Normal" AVF Flow

I prefer to see (and we use) a cutoff of 750 ml/min. In fact, ideally, we aim for a flow of ~1000 ml/min. If an AVF flow falls by 25% or more in any given 4 months, this should trigger AVF exam with ultrasound or a fistulogram. Flows can be too high, too—most see 2000 ml/min as too high.

How do you care for a dialysis access site? ›

Wash with an antibacterial soap each day, and always before dialysis. Do not scratch your skin or pick the scab. Check for redness, a feeling of excess warmth, or the beginning of a pimple on any area of your access. Ask your dialysis care team to rotate the needles when you have your dialysis treatment.

How do you care for dialysis access? ›

Access care
  • Wash your access site every day. ...
  • Wash your access site before every dialysis treatment.
  • Don't scratch your access. ...
  • Dialysis staff should clean your access site with an antiseptic before putting the needles in.

What can you not do with AV fistula? ›

Avoid sleeping on your fistula arm. Do not use sharp objects near your fistula arm, for example razors. Avoid carrying heavy loads or shopping bags directly over your fistula. Do not remove scabs from the needle sites; this may cause bleeding or infection.

How long is the recovery from dialysis fistula surgery? ›

It can take several weeks for the AV fistula to heal and become sturdy enough to withstand the rigor of dialysis treatments. Over the weeks following surgery, the high-pressure blood flow from the artery stretches the walls of the vein.

How long does a dialysis fistula surgery take? ›

Arteriovenous fistula surgery is an outpatient procedure, and an overnight stay at the hospital is rarely needed. You will receive either local or general anesthesia for the surgery. The surgeon accesses the artery and vein through a small incision in your arm. The operation takes about an hour.

What can go wrong with fistula surgery? ›

Common complications from fistula surgery include infection, bleeding, and adverse reactions to the anesthetic.

How long does it take to fully recover from fistula surgery? ›

Most people can go back to work and their normal routine 1 to 2 weeks after surgery. It will probably take several weeks to several months for your fistula to completely heal. This depends on the size of your fistula and how much surgery you had.

What foods should you avoid after fistula surgery? ›

Some of the foods need to be avoided are:
  • Spicy Food. Patients of anal fistula must avoid spicy and acidic foods. ...
  • Fried and Fatty Food. ...
  • Say no to Alcohol and Caffeine. ...
  • Red Meat. ...
  • Avoid Sugary Foods.
Jan 29, 2024

What are the complications of dialysis grafts? ›

Although AV fistulas are preferred for hemodialysis, AV grafts are sometimes necessary but have higher failure rates. Failure can be related to stenotic lesions affecting the feeding arteries, within the graft or in the draining veins, including the central veins.

What are the complications of AV grafts for dialysis patients? ›

Immediately after surgery, hemorrhage, low venous flow or hematoma may occur. At a later stage, there may be complications, such as infections, the development of an aneurysm and/or false aneurysm, fistula vein stenosis, congestive heart failure, steal syndrome, ischemic neuropathy and thrombosis (table 1).

What is the most common cause of AV graft failure? ›

Similar to fistulas, graft thrombosis is most often due to neointimal hyperplasia which forms stenosis and subsequent decrease in access flow and thrombosis. The most common lesion is juxta-anastomotic stenosis.

What is the major cause associated with the failure of the arteriovenous graft? ›

Often, these failures stem from the development of thrombosis-the formation of blood clots within the blood vessels. Thrombosis can obstruct the necessary high-volume blood flow, rendering the AVF or graft unusable for hemodialysis and requiring immediate medical intervention [2].

Top Articles
Latest Posts
Article information

Author: Reed Wilderman

Last Updated:

Views: 5786

Rating: 4.1 / 5 (72 voted)

Reviews: 87% of readers found this page helpful

Author information

Name: Reed Wilderman

Birthday: 1992-06-14

Address: 998 Estell Village, Lake Oscarberg, SD 48713-6877

Phone: +21813267449721

Job: Technology Engineer

Hobby: Swimming, Do it yourself, Beekeeping, Lapidary, Cosplaying, Hiking, Graffiti

Introduction: My name is Reed Wilderman, I am a faithful, bright, lucky, adventurous, lively, rich, vast person who loves writing and wants to share my knowledge and understanding with you.