What is Dialysis Access ?

Dialysis access is an entranceway into your bloodstream that lies beneath your skin and is easy to use. The access is usually in your arm or leg and allows blood to be removed and return ed quickly, efficiently, and safely during dialysis.

Dialysis, also called hemodialysis, is the most common treatment for kidney failure. A dialysis machine is an artificial kidney designed to remove impurities from your blood. Physicians use dialysis to circulate your blood through the machine to remove impurities and regulate fluid and chemical balances.

There are two types of portals:

• Fistula, which your physician creates by joining an artery to a vein

• Graft, which is a man-made tube that connects an artery to a vein

• For both fistulas and grafts, the connection between your artery and vein increases blood flow through the vein. In response your vein stretches and becomes strengthened. This allows an even greater amount of blood to pass through the vein

• In the weeks after surgery, the fistula begins to mature. The vein increases in size and may look like a cord under your skin.

• The whole process typically takes 3 to 6 months. Some fistulas take as long as a year or more to develop fully.

• Once matured, a fistula should be large and strong enough for dialysis technicians and nurses to insert the large dialysis needles easily.

• You can usually begin using your graft in 2 to 6 weeks, when it is healed sufficiently.

• Usually fistulas are preferred to grafts because fistulas are constructed using your own tissue, which is more durable and resistant to infection than are grafts.  However, if your vein is blocked or too small to use, the graft provides a good alternative. 

What can I expect?

• Before choosing the access site, your surgeon may ask you if you have a history or symptoms of arm or leg artery disease. Hardening of the arteries, which reduces blood flow to your arms or legs, causes these conditions.

• Your vascular surgeon will not place a dialysis access site in an area of the body with reduced circulation. For this reason, your surgeon usually places dialysis access sites in the arms rather than in the legs because atherosclerosis is more common in the legs.

• Your vascular surgeon may order a blood flow test in your arms and legs, such as an ultrasound exam, or an x ray, such as a venogram, to determine whether your veins are large enough to qualify for a fistula.

• Sometimes a non-invasive arterial doppler test is used to evaluate the flow in your arteries if this is a concern to your surgeon.

• Your vascular surgeon will give you the necessary instructions you need to follow before the surgery, such as fasting. Usually, your physician will ask you not to eat or drink anything 8 hours before your procedure.

•  Your physician will discuss with you whether to reduce or stop any medications that might increase your risk of bleeding or other complications.

• You will have the procedure on an outpatient basis.

•  Most often, you will first be sedated and then your surgeon will numb the area where the fistula or graft will go. In some cases, your anesthesiologist may put you to sleep.

• Depending upon the quality of your artery and vein, your surgeon will construct the fistula with one incision using the forearm of the arm that you do not use as frequently. For example, if you're left handed, your physician will place the fistula in your right arm, if possible.

•  To perform the surgery, your physician joins an artery and a large vein under the skin. The physician divides your vein and sews it to an opening made in the side of the artery. As a result, blood flows into the veins that lead back to your heart, and also down the arteries into the hand. The blood normally traveling in your divided vein goes back to the heart through other veins.
 
• If you cannot receive a fistula because the vein is too small or blocked, your physician may construct a graft using a piece of man-made material.

• Your physician sews the graft to one of your veins and connects the other end to an artery. Your physician may place the graft material straight or form a loop under the skin either in your lower arm, upper arm, or occasionally in your leg.

What can I expect after dialysis access?

• After the operation, you should initially keep the access area raised above your heart to reduce swelling and pain.

• Your surgeon may recommend an over-the-counter painkiller to relieve pain, if necessary.

What can I do to keep my new access site working properly in the weeks after the surgery?

• Keep the incision dry for at least 2 days after the procedure and do not soak or scrub the incision until it has healed

• Avoid lifting more than about 15 pounds or other activities that stress the access area, such as digging

• Report pain, swelling, or bleeding immediately to your physician, especially if these symptoms are becoming worse. Some pain or swelling is common and not worrisome if decreasing, but you should tell your physician if you have bleeding or a fever higher than 101 degrees Fahrenheit

• You may feel some coolness or numbness in the hand with the fistula. These sensations usually go away in a few weeks as your circulation compensates for the fistula. However, if these sensations are severe or don’t disappear, tell your physician as soon as possible, because the fistula may be causing too much blood to flow away from your hand, a condition physicians call a “steal.”

• You should perform exercises to grow and strengthen your fistula, after the pain from the surgery decreases, to make dialysis faster and easier. Your physician may recommend squeezing a soft object with the hand in the arm with the fistula.

• Grafts mature more quickly than fistulas. They sometimes can be ready in 2 to 3 weeks, but many physicians recommend waiting about 4 to 6 weeks before using a graft.

•  Grafts are more likely than fistulas to become infected. Grafts usually last about 1 to 2 years, which is less than fistulas.

•  Fistulas can often last up to 3 to 7 years. If you care properly for your graft, however, you can help it last for many years.

• Sometimes portals can take weeks or even months until they are ready for dialysis use. Until the portal is ready, you may have to use a catheter for dialysis.

Are there any complications?

Complications with dialysis access include:

• Clotting
• Narrowing
• Infection
• Bleeding

What can I do to keep my access site working properly?

Protecting the dialysis access is crucial for you. The following tips will help you care for a fistula or a graft:

• Check several times each day to make sure the access is functioning
• Monitor any bleeding after dialysis. If the graft seems to bleed longer than usual from the needle sites, you should notify your dialysis center staff
• Do not carry heavy items with the arm that has the access
• Do not sleep on that arm
• Do not wear any clothing or jewelry that binds that arm
• Do not let anyone draw blood or measure blood pressure from that arm
• Do not allow injections to be given into the fistula or graft
• Keep the site of the fistula or graft clean
• After dialysis, monitor the access for signs of infection, such as swelling
• Do not use any creams and lotions over the site of the fistula or graft