Hemodialysis access management

Dialysis is a treatment for people with end-stage renal disease (kidney failure) or an acute (sudden) kidney injury. The procedure removes waste products and extra fluid from your blood when your kidneys don’t work as they should. There are two types of dialysis: hemodialysis and peritoneal dialysis.

In hemodialysis, we remove your blood, use a special machine called a dialyzer to clean it, and return it to your body. Peritoneal dialysis filters blood inside your body using the lining of your abdomen as a filter, without an external machine. Your health-care provider can help you decide which type of dialysis is right for you.

Before your procedure to create the dialysis access site, we do a thorough physical exam and review your medical history. You also have imaging exams such as a Doppler ultrasound or angiogram. These tests map your blood vessels and measure blood flow through veins and arteries, which help us select the right location for your access site. Your care team will provide additional instructions about how to prepare for the procedure.

The surgery to create the fistula or graft is usually an outpatient procedure, so you go home the same day. It typically takes one to three hours.

During AV fistula or graft surgery, here’s what you can expect:

1. A nurse applies a local anesthetic to your arm to numb the area.
2. You receive a sedative through an IV in your arm. In some cases, you have general anesthesia.
3. A surgeon makes a small incision (cut) in your arm.
4. They sew together an artery and vein (for fistulas) or join an artery and vein using a tube (for grafts).
5. The surgeon closes the incision and applies a sterile bandage to the wound.

Someone will need to drive you home after the procedure. We recommend taking a few days off work to recover. Your care team will give you instructions about how to care for your fistula, graft, or catheter. It’s important to keep the access site clean and dry.

The best way to detect problems with your graft or fistula is to examine it regularly (such as on your dialysis days) and note changes from the last self-examination. You should feel a soft vibration, like a cat purring, when it’s functioning well. You can feel this by putting the palm of your hand over your graft or fistula. You should examine at least three different points on the access site.

See the dialysis unit or your interventional radiologist at the first signs of a problem with your vascular access, including:

• A hard pulse, like a drumbeat, in the fistula or graft
• Arm swelling
• Bleeding or drainage from the access site
• No pulse in the fistula or graft
• Tenderness, redness, or warmth near the access site

It’s important to monitor your dialysis access and catch problems as early as possible. An interventional radiologist uses a special type of X-ray procedure with a catheter and contrast dye, called a fistulogram, to check your fistula or graft for:

• Stenosis: A vein or artery narrows and prevents adequate blood flow.
• Thrombosis: Blood clots in the fistula block blood flow.
• Accessory veins: Side branches off veins divert blood from the access point.

Minimally invasive, endovascular interventions for fistula or graft problems may include:

• Angioplasty and stenting: procedure to widen a narrowed artery or vein using a catheter, balloon, and mesh tube
• Thrombectomy: procedure to remove a blood clot from a blood vessel
• Embolization: procedure to block blood flow through a blood vessel such as an accessory vein
• Ligation: procedure to tie off a vein or artery to stop blood flow

Our expertise in interventional radiology, vascular surgery, and nephrology (kidney care) qualifies us to handle all aspects of hemodialysis access management. At Penn Medicine, you’ll find:

• Specialized dialysis expertise: We have one of the largest home dialysis programs in the Greater Philadelphia area and the largest academic training program for home dialysis in the Northeast. We offer home, in-center, and nocturnal (overnight) hemodialysis, as well as peritoneal dialysis.
• Advanced technology: We use the latest imaging equipment and catheter-guided endovascular techniques for hemodialysis access surgery and management. Our dialysis centers also feature the most up-to-date dialysis machines.
• Comfort and convenience: With dialysis centers throughout the Greater Philadelphia, Princeton, and Lancaster areas, it’s easy to get the treatment you need close to home. We’re also here to give you options and support for home dialysis, so you can spend more time living your life.