Hemodialysis Access

Background

Long-term hemodialysis (HD) requires reliable, repeatable access to the central circulation with sufficient blood flow to deliver adequate dialysis while minimizing infection, thrombosis, and ischemic complications. ^[1]

Access options (typical hierarchy, individualized to the patient's ESKD Life-Plan)

• Arteriovenous fistula (AVF) (autogenous): preferred when feasible due to lower infection risk and durable long-term performance. ^{[1] [2]}
• Arteriovenous graft (AVG) (prosthetic): appropriate when native veins are unsuitable or time-to-cannulation must be shorter; carries higher thrombosis and infection risk than AVF. ^{[1] [2]}
• Central venous catheter (CVC) (tunneled or non-tunneled): provides immediate access but is associated with catheter-related bloodstream infection (CRBSI), central venous stenosis, and worse clinical outcomes; should be minimized when possible. ^{[3] [1]}

Vascular access dysfunction (stenosis, thrombosis, inadequate maturation) remains a major driver of procedures and hospitalizations among HD patients, and contemporary guidelines emphasize a patient-first strategy: "fistula-first when appropriate," rather than fistula-first for every patient. ^{[4] [1]}

Infection prevention is central to access outcomes

• For CVCs, adherence to evidence-based insertion/maintenance bundles reduces CRBSI and other complications. ^{[5] [6]}
• For prosthetic access infection (AVG), management principles overlap with vascular graft infection care (source control, targeted antimicrobials, and selective graft excision/reconstruction). ^[7]

Etiology and Indications

End-stage renal disease (ESRD): The leading causes of ESRD requiring hemodialysis include diabetic nephropathy, hypertensive nephrosclerosis, chronic glomerulonephritis, polycystic kidney disease, and interstitial nephritis. The etiology influences vascular anatomy, comorbidity burden, and access outcomes. ^[1]

Indications for access creation: Patients with chronic kidney disease should be referred for vascular access evaluation when the estimated glomerular filtration rate (eGFR) approaches 15–20 mL/min/1.73 m², or earlier if rapid renal function decline is anticipated. This timing allows for access creation and maturation before dialysis initiation, minimizing reliance on central venous catheters. ^[1]

Access selection factors: The choice between arteriovenous fistula (AVF), arteriovenous graft (AVG), or catheter-dependent access should be individualized based on multiple factors:

• Life expectancy and dialysis timeline: Patients with limited life expectancy or urgent dialysis needs may benefit from AVG or catheter rather than awaiting AVF maturation. Consider AVG when AVF maturation is unlikely or time to use must be short.
• Vessel anatomy: Preoperative duplex ultrasound mapping assesses suitability; commonly used thresholds are arterial diameter ≥2.0 mm and venous diameter ≥2.5 mm, though patient-specific variation exists.
• Prior access history: Previous access failures, central venous catheter exposure, and central venous stenosis influence planning and site selection.
• Comorbidities: Diabetes, peripheral arterial disease, obesity, and cardiac function affect access choice, maturation potential, and complication risk.

These factors are emphasized in contemporary vascular access guidelines and should be integrated into shared decision-making. ^[1],[2]

Pathophysiology of Access Maturation and Failure

AVF maturation: Successful arteriovenous fistula maturation requires venous arterialization characterized by increased venous diameter, wall thickening, and elevated blood flow. The traditional “rule of 6s” (flow ≥600 mL/min, diameter ≥6 mm, depth ≤6 mm from the skin surface) provides a helpful guide, but clinical suitability is ultimately defined by the ability to achieve reliable two-needle cannulation and deliver adequate dialysis. ^[1]

Failure to mature: Primary failure of AVF maturation occurs in 20–50% of cases and is most commonly due to small or sclerotic native veins, inadequate arterial inflow, juxta-anastomotic stenosis, or competitive flow through accessory veins. ^[1]

Access stenosis: Stenosis is the most common cause of access dysfunction and typically results from neointimal hyperplasia at the arteriovenous anastomosis or within the venous outflow tract. Repetitive needle trauma, turbulent flow, and biomechanical stress contribute to progressive venous narrowing. ^[1],[8]

Thrombosis: Access thrombosis is most often superimposed on hemodynamically significant stenosis that reduces flow below a critical threshold. Acute thrombosis presents as loss of the characteristic thrill and bruit. ^[1]

Steal syndrome: Arterial steal syndrome results from diversion of arterial blood through the low-resistance arteriovenous connection, leading to distal limb ischemia. Risk factors include diabetes, 10peripheral arterial disease, and brachial artery inflow fistulas. ^[1]

High-output heart failure: High-flow arteriovenous fistulas (typically >2 L/min) can precipitate or exacerbate congestive heart failure in patients with limited cardiac reserve, particularly in the setting of pre-existing cardiomyopathy. ^[1]

Clinical Presentation

• Mature access: palpable thrill, audible bruit, flow >600 mL/min.
• Complications:
• Limb ischemia (steal).
• Aneurysm/pseudoaneurysm.
• Infection (more common in AVG/CVC).
• Recurrent thrombosis or poor dialysis adequacy. ^[1],[2]

Diagnostics

Goals of evaluation

• Confirm the access can be cannulated reliably and deliver adequate dialysis.
• Identify correctable lesions (usually hemodynamically significant stenosis) before thrombosis occurs. ^[1]

Bedside clinical monitoring (first-line "diagnostic test")

• Inspect: arm swelling, collateral veins (suggesting central venous stenosis), skin breakdown over aneurysms/pseudoaneurysms.
• Palpate: continuous thrill (loss suggests thrombosis; focal "water-hammer" pulsatility suggests outflow stenosis).
• Auscultate: continuous low-pitched bruit (high-pitched or discontinuous suggests stenosis). ^{[1] [2]}

Imaging and functional tests for access dysfunction

Common diagnostic pathways

• AVF nonmaturation (4-6 weeks post-creation): DUS to assess low flow, juxta-anastomotic stenosis, accessory veins, inadequate vein dilation, or poor inflow. ^[1]
• Suspected stenosis with dialysis indicators (high venous pressures, recirculation, prolonged bleeding): DUS and/or angiography depending on likelihood of endovascular therapy. ^{[1] [2]}
• Suspected thrombosis: urgent clinical confirmation (absent thrill) -> angiography with intent to treat and address underlying stenosis. ^[1]
• Suspected steal / access-related hand ischemia: focused vascular exam plus noninvasive testing (digit pressures/Doppler) and DUS assessment of inflow and access flow to guide banding vs DRIL/RUDI-type solutions. ^{[1] [2]}

See 3Chapter 3 for general angiographic and duplex principles. ^[9]

Access Creation

Access creation should follow an individualized ESKD Life-Plan that accounts for anticipated dialysis duration, likelihood of transplantation, comorbidity burden, functional status, and patient preferences. ^{[1] [2]}

Principles of access site selection

• Prefer upper-extremity access when feasible (lower infection risk and fewer ischemic complications than lower-extremity options in most patients). ^[1]
• Use a distal-to-proximal strategy to preserve future sites when clinically appropriate. ^[2]
• Minimize CVC exposure because catheters increase the risk of infection and central venous stenosis, jeopardizing future access. ^{[3] [1]}

Preoperative evaluation (standard of care)

• Duplex ultrasound mapping of arteries and veins (diameters, patency, compressibility, depth, and central venous outflow when indicated) improves planning and supports shared decision-making. ^{[1] [2]}

Common autogenous AVF configurations

• Radiocephalic (wrist) AVF: preserves proximal sites; longer maturation and higher early failure in poor vessels.
• Brachiocephalic (antecubital) AVF: higher flow and higher maturation rates but increased risk of steal and high-flow physiology.
• Brachiobasilic transposition AVF: preferred when cephalic vein options are exhausted; typically good long-term patency but requires transposition and careful planning for cannulation segment. ^{[2] [10]}

When prosthetic AVG is appropriate

• Consider AVG when native veins are unsuitable, AVF maturation is unlikely, or time-to-use must be short (to reduce catheter dependence). ^{[1] [2]}

Practical "targets" for usability

• Maturation should be defined by clinical usability (reliable two-needle cannulation and adequate dialysis delivery), not ultrasound thresholds alone, though the "rule of 6s" remains a useful guide. ^[1]

Endovascular Interventions

Percutaneous transluminal angioplasty (PTA): Balloon angioplasty is the first-line endovascular treatment for most access stenoses, whether in native fistulas or prosthetic grafts. The procedure involves advancing a balloon catheter across the stenotic segment and inflating it to restore luminal diameter. Technical success rates exceed 90%, though restenosis is common, particularly at the venous anastomosis of grafts. Drug-coated balloons eluting paclitaxel have demonstrated improved target-lesion primary patency in arteriovenous fistulas compared with plain balloon angioplasty in randomized controlled trials, though ongoing safety surveillance continues. ^{[1],[2],[11],[12]}

Thrombectomy: Acute access thrombosis can often be salvaged through pharmacomechanical or mechanical thrombectomy techniques. These include catheter-directed thrombolysis, rheolytic thrombectomy, and mechanical aspiration devices. Thrombectomy is typically combined with angioplasty to address the underlying stenosis responsible for thrombosis, as failure to correct the causative lesion results in early rethrombosis. ^[1]

Stent-grafts: Covered stents (stent-grafts) are indicated for specific complications including recurrent stenosis refractory to angioplasty, venous rupture during angioplasty, and selected pseudoaneurysms. Randomized data demonstrate superior patency of stent-grafts compared with angioplasty alone for recurrent graft-vein anastomotic stenosis in arteriovenous grafts. Bare metal or covered stents may also be used for central venous stenosis with elastic recoil after balloon angioplasty. ^[13],[1],[2]

Surgical Interventions

Surgical therapy is indicated when endovascular options are not durable/feasible, when complications threaten limb or life, or when access anatomy requires open revision for usability. ^{[1] [2]}

Common surgical indications

• Recurrent stenosis not responding to percutaneous therapy.
• Nonmaturation requiring revision (e.g., revision of juxta-anastomotic segment, superficialization/transposition to enable cannulation). ^[1]
• Symptomatic aneurysm/pseudoaneurysm (skin thinning, ulceration, infection, inability to cannulate safely).
• Access-related hand ischemia requiring flow reduction or revascularization procedures.
• Infection, particularly prosthetic AVG infection requiring source control. ^[7]

Typical surgical options

• Revision of anastomosis or jump graft/patch for focal lesions. ^{[14] [2]}
• Aneurysmorrhaphy or segmental replacement for unsafe aneurysmal degeneration (avoid loss of future cannulation sites when possible). ^[1]
• Steal/ischemia operations (procedure selection depends on access flow and distal perfusion)
• Banding / flow reduction (selected patients).
• DRIL (distal revascularization and interval ligation) for severe ischemia with preservation of access. ^[15]
• RUDI (revision using distal inflow) in selected high-flow brachial-based accesses. ^[1]
• Excision of infected prosthetic material with staged reconstruction when needed. ^{[7] [2]}

For operative technique detail, see Rutherford's Vascular Surgery and Endovascular Therapy. ^[16]

Complications and Management

Complications should be approached by defining the dominant failure mode (stenosis, thrombosis, infection, ischemia, high-flow physiology, structural degeneration) and selecting the least invasive durable therapy that preserves future access options. ^{[1] [2]}

1) Stenosis and access dysfunction

• Most clinically significant access dysfunction is driven by hemodynamically significant stenosis (often outflow/juxta-anastomotic in AVF; graft-vein anastomosis in AVG). ^{[1] [8]}
• Treat when there are clinical indicators (cannulation difficulty, prolonged bleeding, elevated venous pressures, recirculation, inadequate dialysis), not ultrasound findings alone. ^[1]

2) Thrombosis

• Acute thrombosis is usually superimposed on untreated stenosis; successful salvage requires thrombus removal and correction of the culprit lesion. ^[1]
• Catheter-associated upper extremity DVT should be managed using evidence-based VTE principles (anticoagulation when indicated, balancing bleeding risk and access needs). ^{[17] [18]}

3) Infection

• CVC infection (CRBSI): apply standardized diagnostic and management pathways (cultures, systemic antibiotics, and catheter removal/exchange strategies based on organism and clinical severity). ^{[6] [5]}
• AVG infection: higher risk than AVF; management prioritizes source control (often requires partial/total graft excision) plus pathogen-directed antimicrobials, consistent with vascular graft infection principles. ^{[7] [2]}
• AVF infection: less common; treat with antibiotics and drainage/debridement when localized; excision is reserved for uncontrolled infection or septic complications. ^[1]

4) Access-related hand ischemia (steal syndrome)

• Risk factors: diabetes, 10peripheral arterial disease, brachial artery inflow, prior arterial reconstruction. ^[1]
• Management is symptom- and physiology-driven:
• Optimize systemic factors and confirm diagnosis (digital pressures/Doppler; DUS flow).
• Flow reduction procedures (selected high-flow accesses).
• DRIL is a durable option for severe ischemia with access preservation. ^{[15] [1]}

5) Aneurysm and pseudoaneurysm

• Often related to repetitive cannulation and outflow stenosis.
• Red flags: rapid growth, pain, skin thinning/ulceration, infection, or inability to cannulate safely -> surgical repair or endovascular exclusion in selected cases (while preserving cannulation options when possible). ^{[1] [2]}

6) Central venous stenosis/occlusion (CVS)

• Prevention: avoid subclavian catheterization when possible; minimize catheter exposure. ^{[1] [3]}
• Treat symptomatic CVS only (arm swelling, collateral veins, access dysfunction). ^{[1] [2]}
• First-line: balloon angioplasty; reserve stents/stent-grafts for elastic recoil, rupture, or recurrent stenosis, and avoid stenting across pacemaker/ICD leads when feasible. ^{[1] [2]}

7) High-flow access and heart failure

• High access flow can precipitate or worsen heart failure in susceptible patients; management includes flow reduction and, when necessary, access revision/ligation guided by symptoms and hemodynamics. ^[1]

Follow-up and Surveillance

Follow-up aims to (1) ensure AVF maturation and usability, and (2) detect clinically meaningful dysfunction early enough to prevent thrombosis and catheter dependence. ^[1]

Suggested follow-up framework (adapt to local dialysis workflow and ESKD Life-Plan)

Clinical monitoring is primary

• KDOQI emphasizes that clinical indicators should drive evaluation and intervention. ^[1]

Instrument-based surveillance is adjunctive

• Access flow measurement and/or DUS surveillance may be used in selected high-risk settings, but abnormal metrics alone should not trigger preemptive angioplasty without corroborating clinical findings. ^[1]

Guidelines

KDOQI Guidelines (2019): The Kidney Disease Outcomes Quality Initiative (KDOQI) 2019 guidelines advocate an individualized “ESKD Life-Plan” that balances patient life expectancy, comorbidities, functional status, and vascular anatomy with the preference for autogenous access when appropriate. Key recommendations include timely referral (eGFR 15–20 mL/min/1.73 m²), preoperative vessel mapping, emphasis on clinical monitoring over instrument-based surveillance, and avoidance of routine preemptive angioplasty based solely on abnormal surveillance metrics without clinical indicators of dysfunction. ^[1]

ESVS Guidelines (2018): The European Society for Vascular Surgery (ESVS) 2018 guidelines recommend autogenous arteriovenous fistula as the first-choice access when feasible, given superior long-term patency and lower complication rates. The guidelines provide specific indications for stent-graft use, including recurrent graft-vein anastomotic stenosis, venous rupture during angioplasty, and selected pseudoaneurysms. Preoperative duplex ultrasound mapping is recommended to optimize access planning. ^[2]

SVS Guidelines (2008): The Society for Vascular Surgery (SVS) 2008 practice guidelines established foundational standards for access creation, surveillance, and intervention. While these remain historically important, contemporary practice should align with the updated recommendations provided by KDOQI 2019 and ESVS 2018, which incorporate more recent evidence regarding surveillance strategies, endovascular techniques, and individualized access planning. ^[14]

Tables

Table 18.1. Comparison of Hemodialysis Access Options (clinically oriented) ^{[1] [2] [3]}

Table 18.2. Clinical Indicators of Access Dysfunction (trigger evaluation) ^[1]

Table 18.3. Selected Complications and First-Line Management ^{[1] [2] [7] [6]}

Access planning using an ESKD Life-Plan and timing of referral/creation

The ESKD Life-Plan is an individualized approach to vascular access planning that integrates patient prognosis, comorbidities, and treatment goals. Patients should be referred for vascular access evaluation when the estimated glomerular filtration rate (eGFR) approaches 15–20 mL/min/1.73 m² or earlier if rapid decline is anticipated. Early vessel mapping using duplex ultrasound identifies suitable anatomy and allows sufficient time for fistula creation and maturation. Access choice should align with life expectancy, anticipated dialysis duration, modality preference (hemodialysis versus peritoneal dialysis), and patient-specific anatomic and functional considerations. This comprehensive planning minimizes reliance on central venous catheters and optimizes long-term access durability. ^[1],[2]

AVF maturation optimization (postoperative DUS, balloon-assisted maturation, early stenosis management)

Optimizing arteriovenous fistula (AVF) maturation requires systematic postoperative assessment and timely intervention when indicated. A duplex ultrasound performed at 4–6 weeks postoperatively can identify factors impeding maturation, including juxta-anastomotic stenosis, inadequate arterial inflow, competing accessory veins, and insufficient venous diameter or flow. Clinical criteria for intervention include failure to develop a palpable thrill, absence of progressive venous enlargement, or inability to cannulate by 3–4 months. Balloon-assisted maturation techniques include percutaneous transluminal angioplasty of juxta-anastomotic or other flow-limiting stenoses and ligation or embolization of accessory veins that divert flow away from the main cannulation segment. These interventions can salvage otherwise failing fistulas and reduce dependence on central venous catheters. ^[1]

When to choose AVG over AVF (elderly, limited life expectancy, poor vessels)

While autogenous arteriovenous fistulas (AVFs) are preferred when feasible, arteriovenous grafts (AVGs) may be the superior initial choice in selected patients. Indications for AVG-first strategies include advanced age or frailty with limited life expectancy, inadequate venous anatomy (small diameter <2.5 mm or extensively sclerotic veins), urgent need for hemodialysis when fistula maturation time would necessitate prolonged catheter use, and patient preference after informed discussion. Early-cannulation prosthetic grafts with reinforced designs can be accessed within days to weeks rather than months, further reducing catheter exposure in appropriate candidates. The decision should balance individual patient factors with the known higher rates of thrombosis and infection associated with prosthetic grafts. ^[1],[2]

Central venous stenosis (CVS): evaluation and management nuances

Central venous stenosis (CVS) is a common complication in hemodialysis patients, particularly those with a history of central venous catheterization. Prevention is paramount; subclavian vein catheterization should be avoided whenever possible due to the high risk of stenosis that can compromise ipsilateral upper extremity access. Asymptomatic central venous stenosis detected on imaging should not be treated, as intervention is reserved for clinically significant lesions causing ipsilateral arm swelling, access dysfunction, or symptomatic collateral venous distension. Percutaneous transluminal angioplasty is the first-line treatment for symptomatic CVS. Stents or stent-grafts are reserved for specific indications including elastic recoil, venous rupture during angioplasty, or recurrent stenosis after prior balloon angioplasty. Stent placement across cardiac pacemaker or implantable cardioverter-defibrillator (ICD) leads should be avoided when feasible due to potential lead entrapment and future extraction difficulties. In refractory cases unsuitable for endovascular therapy, surgical bypass or hybrid devices such as the Hemodialysis Reliable Outflow (HeRO) graft provide alternative solutions. ^[1],[2]

Evidence update on drug-coated balloons (DCB) for AVF stenosis

Recent randomized controlled trial evidence has demonstrated that drug-coated balloons (DCBs) improve target-lesion primary patency in arteriovenous fistulas compared with plain balloon angioplasty. Paclitaxel-eluting balloons show promise in reducing restenosis rates and extending the interval to repeat intervention. However, the use of paclitaxel-coated devices remains subject to ongoing safety surveillance following concerns raised in the peripheral arterial disease literature. Clinicians should remain informed of evolving regulatory guidance and evidence regarding the risk-benefit profile of drug-coated technologies in the dialysis access setting. ^[11]