What is Dialysis Access?
Dialysis access refers to the surgically created connection point that allows blood to be drawn from the body, filtered through a hemodialysis machine, and returned. For patients with end-stage renal disease (ESRD) whose kidneys can no longer adequately filter waste and excess fluid from the blood, hemodialysis is a life-sustaining treatment that must be performed multiple times each week. A well-functioning vascular access is essential for effective dialysis.
There are three primary types of dialysis access: arteriovenous (AV) fistulas, arteriovenous (AV) grafts, and central venous catheters. An AV fistula, created by surgically connecting an artery directly to a vein (typically in the forearm or upper arm), is considered the gold standard because it offers the longest lifespan, lowest infection rate, and fewest complications. An AV graft uses a synthetic tube to bridge the artery and vein when a direct connection is not possible. Central venous catheters provide immediate access but carry higher risks of infection and are generally intended for temporary or urgent use.
At Vascular Surgical Associates, our team of board certified Vascular Surgeons has extensive experience creating all types of dialysis access, as well as managing the complications and revisions that access sites may require over time. We work closely with nephrologists and dialysis centers throughout metro Atlanta to coordinate care and ensure that every patient has a reliable, functioning access site. With 7 office locations and an in-office angio suite, we can provide timely evaluations and interventions to keep dialysis on track.
Signs of Access Dysfunction
Recognizing the early warning signs of a failing dialysis access is critical for timely intervention. If you notice any of the following changes, contact your vascular surgeon or dialysis center promptly:
Decreased Thrill or Bruit
A healthy AV fistula or graft has a palpable vibration (thrill) and an audible rushing sound (bruit). A weakening or absent thrill or bruit may indicate clotting or narrowing within the access.
Arm Swelling
Persistent or worsening swelling in the arm with the access site may suggest venous stenosis (narrowing) or obstruction that is preventing blood from draining properly.
Prolonged Bleeding After Dialysis
If bleeding from the needle sites takes significantly longer than usual to stop after a dialysis session, it may indicate elevated pressure within the access due to downstream narrowing.
Difficulty with Cannulation
If the dialysis staff has increasing difficulty inserting needles into the access, or if the access collapses during needle placement, it may indicate stenosis or insufficient maturation.
Inadequate Dialysis
Poor clearance numbers (low Kt/V), elevated venous pressures during dialysis, or recirculation of blood within the access can all point to a malfunctioning access that needs evaluation.
Risk Factors for Access Complications
Diabetes
Diabetes is the leading cause of ESRD and also damages blood vessels, making fistula creation more challenging and increasing the risk of access failure due to poor vessel quality.
Peripheral Vascular Disease
Existing arterial disease reduces blood flow to the arm, which can impair fistula maturation and limit the options available for access placement.
Previous Failed Access
Each prior access attempt uses available vessels and creates scar tissue, making subsequent access creation more complex and reducing the number of viable sites.
Venous Stenosis
Prior central venous catheters, PICC lines, or pacemaker leads can cause scarring and narrowing of the central veins, impeding outflow from the access and leading to dysfunction.
Advanced Age
Older patients may have less robust veins and arteries, which can increase the likelihood of fistula maturation failure and the need for alternative access strategies.
Evaluation & Diagnosis at VSA
Proper evaluation before access creation and ongoing surveillance of existing access sites are central to successful dialysis outcomes. At Vascular Surgical Associates, we begin with a thorough physical examination of both arms, assessing the arteries and veins by palpation and evaluating the quality of the vascular system.
Our ICAVL-accredited vascular laboratory performs pre-operative vein mapping using duplex ultrasound to identify the best vessels for fistula or graft creation. This detailed assessment measures the diameter and depth of arm veins and evaluates arterial inflow, allowing our surgeons to select the optimal site and configuration for your access. Vein mapping has been shown to improve fistula success rates by matching the surgical plan to the patient’s individual anatomy.
For patients with a malfunctioning or failing access, we use duplex ultrasound to identify stenosis, thrombosis, or other structural problems. When more detailed imaging is needed, a fistulagram (contrast angiography) can be performed in our in-office angio suite, providing real-time visualization of the entire access circuit. This study allows our surgeons to identify and often treat narrowing or clotting during the same session, minimizing disruption to your dialysis schedule.
Treatment Options
Our vascular surgeons provide the full spectrum of dialysis access procedures, from initial creation to complex revision surgery. We follow the Fistula First approach, prioritizing AV fistulas whenever possible for their superior outcomes and longevity.
AV Fistula Creation
An arteriovenous fistula is created by surgically joining an artery to a vein, usually in the forearm (radiocephalic fistula) or upper arm (brachiocephalic fistula). Over the following weeks, increased blood flow causes the vein to enlarge and thicken—a process called maturation—making it strong enough for repeated needle access. A mature fistula provides the highest flow rates, lowest complication rates, and longest functional lifespan of any access type, often lasting many years.
AV Graft Placement
When a patient’s veins are not suitable for a direct fistula, an arteriovenous graft uses a synthetic tube (typically made of PTFE) to connect an artery to a vein. Grafts can usually be used for dialysis within two to three weeks of placement, making them a good option when a quicker start to dialysis is needed. While grafts have a somewhat shorter lifespan than fistulas and may require more frequent maintenance, they remain an effective and reliable form of access.
Central Venous Catheter Placement
A tunneled dialysis catheter is inserted into a large vein in the neck or chest and provides immediate access for hemodialysis. Catheters are typically used as a temporary bridge while a fistula or graft matures, or for patients who have exhausted other access options. Our surgeons place catheters using ultrasound and fluoroscopic guidance to ensure precise positioning and minimize complications.
Access Revision & Salvage
When a fistula or graft develops problems such as stenosis, aneurysm formation, or steal syndrome, our surgeons perform revision procedures to restore function and extend the life of the existing access. Surgical revision may involve patch angioplasty, interposition grafting, transposition of the vein, or ligation of problematic branches. Preserving a functioning access site is always preferred over creating an entirely new one.
Angioplasty & Stenting for Stenosis
Narrowing within a fistula, graft, or the draining veins is the most common cause of access dysfunction. Using our in-office angio suite, our surgeons perform balloon angioplasty to open the narrowed segments and restore adequate blood flow. In some cases, a stent may be placed to maintain the opening. These minimally invasive interventions can often be completed as outpatient procedures, allowing patients to resume dialysis the same day.
Thrombectomy
When a clot forms within a fistula or graft, urgent intervention is needed to restore blood flow and prevent the loss of the access. Our surgeons perform both surgical and catheter-based thrombectomy to remove clots, often combined with angioplasty to treat any underlying stenosis that caused the clot to form. Prompt thrombectomy can often salvage an access that would otherwise need to be replaced.
Frequently Asked Questions
An AV fistula uses your own blood vessels, which means it carries the lowest risk of infection compared to grafts and catheters. Fistulas also tend to last the longest—often five years or more—require fewer interventions, and provide excellent blood flow for dialysis. National guidelines and the Fistula First initiative recommend AV fistulas as the preferred access type for patients who are candidates. Our surgeons perform thorough vein mapping to determine whether a fistula is the right option for you.
A newly created AV fistula typically requires 6 to 12 weeks to mature before it can be used for dialysis. During this maturation period, the connected vein gradually enlarges and develops thicker walls in response to the increased blood flow from the artery. This is why it is important to plan ahead: ideally, an AV fistula should be created several months before dialysis is expected to begin. Your vascular surgeon will monitor the fistula’s maturation with regular examinations and ultrasound to confirm it is ready for use.
There are several steps you can take to help keep your access functioning well. Check the thrill (vibration) in your fistula or graft several times each day. Avoid wearing tight clothing, jewelry, or watches on the access arm. Do not allow blood pressure measurements or blood draws on that arm. Keep the access site clean and watch for signs of infection such as redness, warmth, or drainage. Perform the hand-squeezing exercises your surgeon recommends to help the fistula mature and stay healthy. Report any changes or concerns to your vascular surgeon right away.
If you can no longer feel the thrill or hear the bruit in your access, it may have clotted. This is an urgent situation—contact your vascular surgeon or Vascular Surgical Associates immediately. Time-sensitive intervention such as thrombectomy or thrombolysis can often restore the access if performed promptly. Do not wait until your next scheduled dialysis session to report a change. Our team prioritizes urgent access evaluations to help preserve your lifeline to dialysis.
