Dialysis Planning and Access

If your kidneys fail, unless and until you have a successful kidney transplant, you will need dialysis therapy to clean and filter your blood. Dialysis requires ongoing access to your body’s major blood vessels, using one of the following approaches:

A tunneled catheter in your neck—this approach is temporary, because the possibility of infection is high. It is typically used for someone in need of immediate dialysis who has not yet received a more permanent access solution.
An AV fistula—an arteriovenous (AV) fistula is created by taking a piece of a vein from your arm or leg and sewing it into a nearby artery. This allows the sewn-in vein to enlarge and become thicker, like an artery. It is considered the best option for hemodialysis because it has the lowest risk of infection, and the greatest long term result
An AV graft—the sewing of a prosthetic graft between an artery and vein in your arm or leg. This is the preferred option if your veins are too small for an AV fistula. AV grafts tend to close more quickly and are more prone to infection because they are not formed from natural tissue.
A Percutatious Fistula—for many patients their veins are large enough to create a special fistula with a single needle stick under local anesthesia in the office.

Creating an AV fistula

Most patients who require dialysis will require an AV fistula. It is created in your non-dominant arm, so if you are right-handed, the AV fistula will be created in your left arm.

Assessment

Your dialysis access surgeon will explain the procedure and perform a physical exam, focusing on the arm or leg selected. Usually, an ultrasound scan is used to “map” your veins to see if they are large enough for an AV fistula. If not, an AV graft will be needed.

Anesthesia

A variety of anesthesia techniques can be used:

Local anesthesia—numbing medication given by injection at the fistula or graft site, often along with sedation medication given through an IV. This is the most common technique.

General anesthesia—usually involves sedation medication given through an IV, sometimes along with gas that you breathe from a mask, and often includes placing a tube into your throat to make sure you breathe properly.

Procedure

In the operating room, your arm or leg is cleansed with an antiseptic solution and sterile drapes are placed around it.

An incision is made between the artery and vein, and the vessels to be joined are prepared.

If creating a fistula, your surgeon will divide the vein and sew one end to the side of the artery. If a graft will be placed, your surgeon will sew it between the artery and vein.

The incision in your arm or leg will be closed and a sterile dressing will be applied. The fistula then requires approximately 2 to 3 months to develop before it can be used for hemodialysis.

Maintaining your AV fistula or graft

To keep your fistula functioning properly, there are several things that you can do:

Do not have blood tests performed on your fistula arm
Do not wear tight or restrictive clothing on your fistula arm
Avoid sleeping on your fistula arm
Do not carry heavy items (like shopping bags) directly over your fistula

Over time, blood flow can become restricted due to narrowing in the fistula or graft sometimes resulting in clotting. Rarely it can become infected.