Hemodialysis Access

The first step in hemodialysis preparation is establishing access so that treatment can take place. This involves minor surgery that creates a way for the dialysis machine to reach your blood through your vascular system.

Surgeons create vascular access in your arm or leg by placing a shunt, called an arteriovenous (AV) fistula, or with a graft that connects an artery to a vein. Our dialysis access nurses can access your bloodstream by placing two needles into your fistula or graft. If you need hemodialysis urgently, or if your arm or leg access isn’t ready to use when you need dialysis, surgeons may place a catheter in your chest.

We perform your surgery in an operating room after you receive local anesthetic (numbing medicine) at your proposed access site. You also receive sedation. Some people fall asleep during the procedure. Others report minimal discomfort. The surgery itself takes one to two hours. Then, you spend one to three hours in recovery before returning home.

An AV fistula is the best way to establish long-term hemodialysis access. When properly constructed, a fistula can last for years.

Fistula creation involves making a 2 to 4-inch incision in either your wrist, forearm, inner elbow or upper arm. During the procedure, surgeons sew a vein to an artery. An artery is a high-pressure vessel that carries blood away from your heart and delivers oxygen and nutrients to your body’s tissues. A vein is a low-pressure vessel that returns blood back to the heart to begin the process all over again. The fistula creates increased blood flow and pressure in the vein. The goal is to enlarge and strengthen the vein over time so we can eventually use it for your dialysis treatments. We call this process maturation. Usually, the vein will mature enough to start using it for treatment in about eight to 12 weeks.

We cover your incision with a dressing after surgery. If your surgeon closes the incision with dissolvable stitches, we won’t have to remove them. But if you have external stitches, we take them out in two to three weeks.

Not everyone can receive an AV fistula. Numerous needle sticks for IV fluids, blood work and/or medicines can damage veins over time. Veins that are damaged or too small may not enlarge as intended. Worse yet, they may clot. When an AV fistula isn’t suitable at one site, we may recommend creating a fistula at a different site, using an AV graft or placing a catheter.

Possible Fistula Complications

Complications from an AV fistula procedure are possible. Possible complications include infection, bleeding, arm swelling and/or tingling in your fingers.

An unusual but serious complication can occur when the blood from your artery that’s supposed to reach your hand is redirected through the fistula. Sometimes, the fistula functions so well that not enough blood reaches your hand, causing ischemia (lack of oxygen). This condition is called "steal." It usually requires a surgical procedure to establish a new access at a different site.

In an AV graft procedure, surgeons connect an artery and a large vein in your elbow or armpit using a graft made of synthetic fabric that is woven to create a watertight tube. These types of grafts are frequently used to repair blood vessels or perform blood vessel bypass when blockages occur. But they also work well to establish dialysis access.

Surgeons sew the graft to an artery and tunnel it under your skin, creating a loop back to the starting incision. Then, they sew it to a vein. The long loop gives your dialysis access nurse space to access the graft. Your graft incision will have external stitches that we cover with a dressing. We take the stitches out during a follow-up visit.

Unlike with an AV fistula, we don’t have to wait for a vein to enlarge. We can safely use an AV graft for dialysis in about two weeks. Grafts have a lifespan of approximately two to three years but often last longer.

Possible Graft Complications

Unfortunately, AV grafts can be more troublesome than AV fistulas. Blood is more likely to clot in grafts because the grafts are made of prosthetic (foreign) material. When this happens, interventional procedures can remove the clot and restore blood flow for dialysis.

Bleeding, steal and infection are also possible. If a graft becomes infected, we must remove it right away and create a new access site once your infection clears.

Sometimes, we may use a permanent catheter, or permacath, to provide hemodialysis. The catheter penetrates your skin in your chest or neck, but we tunnel it under your skin for several inches before we introduce it into your venous system. Tunneling the catheter reduces your risk of infection.

If doctors need to use a temporary catheter to provide hemodialysis, it penetrates your skin and goes directly into your venous system. Temporary catheters may be appropriate if you need hemodialysis before another access site is ready or if you have a kidney injury that’s expected to heal.

Proper dressing care is vital to prevent infection and help your wound heal.

AV Fistula or Graft Dressings

After surgery, it’s important to keep your dressing dry for two days. During this time, you should not change the dressing. You may notice a small amount of drainage on the dressing. That’s okay. You may cover the area with a clean gauze pad but leave the dressing underneath in place.

After two days, you may remove your dressing. You can then bathe or shower as usual. After your bath or shower, pat the area over your fistula or graft gently with a towel. Don’t rub the area.

In most cases, the wound over your fistula or graft is closed with internal stitches that do not need to be removed. You may see small paper strips called Steri-Strips over your wound. These strips will fall off on their own in about seven to 10 days. (If they fall off sooner, that’s okay. But check to make sure the wound isn’t opening.)

Some redness directly around the incision is normal. If redness or warmth is increasing or spreading, please contact your dialysis access nurse coordinator.

If you notice thick drainage coming from your wound, or if the edges of the wound start to separate, please contact your dialysis access nurse coordinator.

Permacath Dressings

You may have a small dressing over your neck incision. Your dialysis nurse may change this dressing after two days. But you should keep the incision covered until the wound heals. Healing usually takes about seven to 10 days. The nurses in the dialysis unit will change this dressing for you as needed.

Your neck incision won’t have stitches or sutures. But you might see some small paper stitches called Steri-Strips. These will fall off on their own, or your surgeon may remove them about two weeks after your access surgery.

The dressing on your chest is in a very sensitive area. And you need to keep the area covered as long as you have a permacath. It’s important that only nurses in the dialysis unit change this dressing. The nurses will ask you to wear a mask when they change the dressing to help prevent infection.

There is also a stitch at the catheter site in your chest. The dialysis nurse or your surgeon will remove this stitch about three weeks after your access surgery.

It’s important that you avoid getting the dressing on your chest wet. Bacteria can grow easily in a moist environment. If bacteria begin to grow around your permacath, a serious infection could develop at the site or in your bloodstream. Don’t shower or swim with a permacatch in place. It is okay to take a tub bath if you can keep your dressing dry.

Finally, try not to push or pull on your catheter, especially in the first three weeks. And don’t do anything that causes stretching or strain in the area. 

While you heal, it’s important to take some safety precautions.

Hemodialysis AV Fistula or Graft Access Surgery Precautions

After fistula or graft access surgery, keep these tips in mind:  

• Avoid lifting anything that weighs more than 10 pounds for the first three days after surgery. Ten pounds is about the weight of a gallon of milk. Lifting may put strain on the incision before it has time to heal.
• Avoid heavy physical exercise or exertion for two weeks.
• Don’t drive until you’ve stopped taking your prescription pain medication.
• You may go back to routine daily activities as soon as you like provided they don’t involve heavy lifting.

AV Fistula Exercises

While it’s important to avoid certain activities after AV fistula surgery, there are some exercises you should do. They help your fistula enlarge and mature. Start doing the following exercises one week after your surgery.

• Get a tennis ball, Nerf ball or other soft ball you can hold comfortably.
• Place the ball in your hand on the same side as your fistula.
• Squeeze the ball 10 to 15 times a minute for one to two minutes.
• Repeat this exercise 10 to 20 times each day.

Hemodialysis Permacath Access Surgery Precautions

After permacath access surgery, remember these precautions: 

• Avoid lifting anything that weighs more than 10 pounds for the first three days after surgery. Ten pounds is about the weight of a gallon of milk. Lifting may put a strain on your incision before it has time to heal.
• Don’t drive until you have stopped taking your prescription pain medication.
• You may resume other activities such as work, driving, housework and sex whenever you feel ready. Contact your dialysis access nurse coordinator if you have any questions. 

Your access site will need long-term attention to make sure it continues to function well. Please note the following precautions, which you must follow for as long as you have fistula or graft access: 

• Don’t have your blood pressure taken in your access arm.
• Don’t let anyone draw blood or put an IV in your access arm.
• Ask your doctor or nurse about ordering a bracelet that will alert health care providers that you have dialysis access.
• Don’t wear a tight sleeve, watch or other constricting jewelry on your access arm.
• Don’t carry a handbag or briefcase on your access arm.
• Try not to sleep on your access arm.