Part 11/Chapter 61/6-min read

Hemodialysis Access Surveillance, Failure, Central Venous Disease, and Complications

Hemodialysis access surveillance built around function and the patient's overall access life-plan, not around cataloguing every stenosis. The chapter frames monitoring, percutaneous and surgical salvage, central venous obstruction, infection and aneurysmal complications, and steal-syndrome management.

Edited by Tal M. Hörer MD, PhD · David T. McGreevy MD, PhD·Reviewed ·5 sections · 31 references

Listen to this chapter10 min · AI audio edition · two hostsAI narration

Planning conference: A practical planning-room conversation: anatomy, device or operative choices, surveillance, complications, and decision boundaries.

General medical education, not patient-specific advice.

Choose the hosts

Definition and presentation

Access dysfunction is the clinical failure of an arteriovenous fistula or graft to deliver prescribed hemodialysis, or the development of complications that threaten the circuit, limb, or patient. Malfunction is classified structurally into thrombotic events, nonthrombotic flow-related dysfunction, and infectious complications .

Presenting features of access failure or complication include:

  • Difficult cannulation, prolonged post-dialysis bleeding, or inadequate dialysis delivery.
  • Recurrent circuit thrombosis.
  • Arm or facial swelling, and prominent chest-wall collateral veins.
  • Aneurysmal expansion, threatened overlying skin, or localized pain.
  • Hand ischemia, neuropathy, or distal hypoperfusion.
  • Signs of local or systemic infection.
  • Altered physical examination findings, including changes in pulse, thrill, bruit, or collapse with arm elevation.

Central venous disease presents with recurrent access dysfunction, anatomically discordant swelling, and repeated outflow restenosis. In hemodialysis-related venous thoracic outlet syndrome, extrinsic costoclavicular compression is compounded by high distal access flow . Catheter-dependent patients carry higher all-cause mortality, fatal infection, and cardiovascular event risks compared with fistula users, establishing the maintenance of durable permanent access as a core life-preserving strategy . Earlier access creation before dialysis initiation has also been associated with lower subsequent mortality, supporting timely access planning before catheter dependence becomes prolonged.

Surveillance and screening

Guideline frameworks prioritize clinical monitoring and physical examination over universal technology-based screening . There is insufficient evidence to support routine pre-emptive angioplasty of an asymptomatic stenosis; surveillance with treatment on dysfunction remains the position .

Diagnostic imaging is reserved for when a clinical abnormality dictates a change in management. Ultrasound using 10 to 20 MHz transducers is the first-line modality to characterize inflow and outflow stenoses, pseudoaneurysms, hematomas, intimal hyperplasia, and local infection . Fistulography and digital subtraction angiography are used for patients actively progressing to intervention or when central venous obstruction is suspected. Central venous stenosis tracks directly with prior central venous catheter or pacemaker exposure; disease incidence and severity increase with total catheter count .

Treatment of access dysfunction

Management of dialysis access is integrated into an individualized end-stage kidney disease life-plan that balances immediate circuit salvage with the preservation of future venous options . The decision to intervene is governed by clinical dysfunction rather than isolated anatomical narrowing. Intervention requires more than a narrowed lumen. A stenosis warrants angioplasty only when diameter reduction exceeds 50 percent and is paired with a clinical or physiologic abnormality: access dysfunction, abnormal access flow, rising venous dialysis pressures, or prolonged bleeding after decannulation. A greater than 50 percent stenosis in isolation, without such an abnormality, does not by itself justify intervention.

Decision threshold

Dialysis access management criteria

  1. Observation
    Asymptomatic stenosis without clinical flow dysfunction
    Continued clinical monitoring
  2. Medical therapy
    Post-declotting of a prosthetic graft
    Individualized antiplatelet therapy weighed against bleeding risk
  3. Endovascular
    Symptomatic flow-related stenosis or central venous obstruction
    Angioplasty; stent grafts for prosthetic venous anastomosis
  4. Open or revision
    Aneurysm with skin threat, resistant stenosis, or severe steal
    Surgical revision, banding, or inflow modification
  5. No intervention
    Exhausted upper-extremity options with prohibitive surgical risk
    Tunneled femoral catheter as a palliative bridge
  6. Emergency or infection
    Rupture, severe ischemia, or systemic infection
    Urgent source control, access ligation, or specific thrombectomy
Source · · · · ·

The stepwise logic for access salvage is executed in sequence:

  1. Clinical dysfunction is confirmed to justify intervention over surveillance.
  2. The entire access circuit is defined, including inflow, cannulation zone, and central outflow.
  3. Endovascular thrombectomy is performed for clotted circuits and mandates concurrent treatment of the underlying culprit stenosis to ensure durable patency.
  4. Plain balloon angioplasty serves as the default for flow-related stenoses, reserving drug-coated balloons or stent grafts for specific restenotic or anatomic variants.
  5. Central venous stenosis is treated with angioplasty first, with escalation to sequential stenting for elastic recoil or rapid recurrence.

Specific anatomic and procedural complications

Peripheral access interventions rely on conventional balloon angioplasty principles. Drug-coated balloons have demonstrated varying efficacy; adverse predictors for their success include target lesions greater than 4 cm, tandem stenoses, and the presence of thrombosis . In prosthetic grafts, stent graft exclusion of venous anastomotic stenosis provides higher 6-month treatment-area patency, circuit patency, and freedom from reintervention than balloon angioplasty alone .

Cephalic arch stenosis is prone to recoil and rupture. The use of undersized stent grafts (stent-to-vessel diameter ratio below 1.0) is associated with higher primary patency, fewer reinterventions, and reduced lateral edge stenosis compared with size-apposed stent grafts . For central venous disease, brachiocephalic stenosis occurs more frequently than subclavian stenosis, and intervention decisions require balancing immediate symptom relief against the compromise of future surgical or endovascular options .

Steal syndrome prevention and treatment involve distal revascularization and interval ligation (DRIL), extension techniques, or inflow proximalization, favored in high-risk patients undergoing radiocephalic or distal configurations . Iatrogenic complications, such as tibial arteriovenous fistulas following distal Fogarty balloon passage, demonstrate the hazards of endovascular instrumentation in heavily calcified or diseased arteries .

Cannulation technique directly impacts circuit longevity and infection rates. Rope-ladder cannulation is the preferred standard; buttonhole cannulation increases bacteremia risk without a corresponding improvement in primary patency or reduction in thrombosis . Pre-implantation imaging is a core principle extending across populations, from assessing anatomical variants and adjacent structures in newborn access to planning adult circuits . Furthermore, one-stage versus two-stage brachiobasilic fistula creation demonstrates no statistically significant differences in maturation, hematoma, or wound infection rates .

Areas of controversy

The efficacy of drug-coated balloons in hemodialysis access is genuinely uncertain. The Lutonix AV trial reported improved target-lesion primary patency with drug-coated versus uncoated balloons, 58% versus 46% at 9 months and sustained at 12 months , and the AcoArt Orchid trial reported higher target-lesion primary patency, 91% versus 67% at 6 months and maintained at 12 months , and a 2023 meta-analysis supports their superiority over plain balloons without mortality differences . However, earlier meta-analyses of multiple trials found no significant improvement in 6-month or 1-year primary patency , tying their use to specific lesion and recurrence patterns rather than universal application.

Additionally, while clinical integration and follow-up are conceptually supported by trial safety frameworks , translating target-lesion patency directly into sustained dialysis-unit function lacks uniformly established interval guidelines, making routine clinical abnormality the primary trigger for reassessment.

References

  1. 1.
    Expert Panels on Interventional Radiology and Vascular Imaging, et al. ACR Appropriateness Criteria® Dialysis Fistula Malfunction. J Am Coll Radiol. 2023.
    American College of Radiology2023
    PubMedDOISource
  2. 2.
    Davies MG, Hart JP. Venous thoracic outlet syndrome and hemodialysis. Front Surg. 2023.
    PubMed CentralReview2023
    PubMedDOISource
  3. 3.
    Associations between Hemodialysis Access Type and Clinical Outcomes. 2013.
    PubMed-indexed articleMeta-analysis / systematic review2013

    Associations between Hemodialysis Access Type and Clinical Outcomes. 2013. doi:10.1681/asn.2012070643.

    PubMedDOISource
  4. 4.
    KDOQI clinical practice guideline for vascular access: 2019 update.
    PubMed-indexed articleClinical practice guideline2019

    KDOQI clinical practice guideline for vascular access: 2019 update. doi:10.1053/j.ajkd.2019.12.001.

    PubMedDOI
  5. 5.
    UK Kidney Association clinical practice guideline on vascular access for haemodialysis.
    PubMed CentralClinical practice guideline2025

    UK Kidney Association clinical practice guideline on vascular access for haemodialysis. doi:10.1186/s12882-025-04374-y.

    PubMedDOISource
  6. 6.
    Pre-emptive correction for haemodialysis arteriovenous access stenosis.
    PubMed CentralMeta-analysis / systematic review2016

    Pre-emptive correction for haemodialysis arteriovenous access stenosis. doi:10.1002/14651858.cd010709.pub2.

    PubMedDOISource
  7. 7.
    Imaging in Vascular Access. Cardiovascular engineering and technology. 2017.
    PubMed-indexed articleReview2017

    Imaging in Vascular Access. Cardiovascular engineering and technology. 2017. doi:10.1007/s13239-017-0317-y.

    PubMedDOI
  8. 8.
    Ultrasound evaluation of access complications: thrombosis, aneurysms, pseudoaneurysms and infections.
    PubMed CentralReview2021

    Ultrasound evaluation of access complications: thrombosis, aneurysms, pseudoaneurysms and infections. doi:10.1177/11297298211018062.

    PubMedDOISource
  9. 9.
    Central Venous Stenosis, Access Outcome and Survival in Patients undergoing Maintenance Hemodialysis. Clinical journal of the American Society of Nephrology : CJASN. 2019.
    PubMed-indexed articleRegistry / cohort2019

    Central Venous Stenosis, Access Outcome and Survival in Patients undergoing Maintenance Hemodialysis. Clinical journal of the American Society of Nephrology : CJASN. 2019. doi:10.2215/cjn.07010618.

    PubMedDOI
  10. 10.
    Central vein stenosis in hemodialysis vascular access: clinical manifestations and contemporary management strategies.
    PubMed CentralReview2023

    Central vein stenosis in hemodialysis vascular access: clinical manifestations and contemporary management strategies. doi:10.3389/fneph.2023.1280666.

    PubMedDOISource
  11. 11.
    Prevalence of Central Venous Stenosis among Black and White ESKD Patients with Dysfunctional Dialysis Access. Journal of health disparities research and practice. 2023.
    PubMed-indexed article2023
    PubMed
  12. 12.
    Role of Antiplatelet Therapy in Hemodialysis Arteriovenous Graft Secondary Patency Following Successful Percutaneous Thrombectomy. Cardiovascular and interventional radiology. 2023.
    PubMed-indexed articleRegistry / cohort2023

    Role of Antiplatelet Therapy in Hemodialysis Arteriovenous Graft Secondary Patency Following Successful Percutaneous Thrombectomy. Cardiovascular and interventional radiology. 2023. doi:10.1007/s00270-022-03329-2.

    PubMedDOI
  13. 13.
    Stent graft versus balloon angioplasty for failing dialysis-access grafts.
    PubMed-indexed articleRandomized controlled trial2010

    Stent graft versus balloon angioplasty for failing dialysis-access grafts. doi:10.1056/nejmoa0902045.

    PubMedDOI
  14. 14.
    MacRae JM, et al. Arteriovenous Access: Infection, Neuropathy, and Other Complications. Can J Kidney Health Dis. 2016.
    PubMed CentralReview2016
    PubMedDOISource
  15. 15.
    Dialysis Access-Associated Steal Syndrome in High-Risk Patients Undergoing Surgery for Hemodialysis Access: A Systematic Review and Meta-Analysis of Preventive Operative Techniques. Cureus. 2023.
    PubMed-indexed articleMeta-analysis / systematic review2023

    Dialysis Access-Associated Steal Syndrome in High-Risk Patients Undergoing Surgery for Hemodialysis Access: A Systematic Review and Meta-Analysis of Preventive Operative Techniques. Cureus. 2023. doi:10.7759/cureus.49612.

    PubMedDOI
  16. 16.
    Radhakrishnan Y, et al. Tunneled femoral dialysis catheter: Practical pointers. J Vasc Access. 2023.
    PubMed-indexed article2023
    PubMedDOI
  17. 17.
    Endovascular management of thrombosed dialysis vascular circuits.
    PubMed CentralReview2022

    Endovascular management of thrombosed dialysis vascular circuits. doi:10.1055/s-0041-1740941.

    PubMedDOISource
  18. 18.
    Factors associated with patency following drug-coated balloon angioplasty of hemodialysis access. Scientific reports. 2025.
    PubMed-indexed articleRegistry / cohort2025

    Factors associated with patency following drug-coated balloon angioplasty of hemodialysis access. Scientific reports. 2025. doi:10.1038/s41598-025-05133-7.

    PubMedDOI
  19. 19.
    Undersized stent graft for treatment of cephalic arch stenosis in arteriovenous hemodialysis access. Scientific reports. 2020.
    PubMed-indexed article2020

    Undersized stent graft for treatment of cephalic arch stenosis in arteriovenous hemodialysis access. Scientific reports. 2020. doi:10.1038/s41598-020-69402-3.

    PubMedDOI
  20. 20.
    Endovascular intravascular intervention for central venous stenosis in maintenance hemodialysis patients: a retrospective observational study. Frontiers in cardiovascular medicine. 2024.
    PubMed-indexed articleRegistry / cohort2024

    Endovascular intravascular intervention for central venous stenosis in maintenance hemodialysis patients: a retrospective observational study. Frontiers in cardiovascular medicine. 2024. doi:10.3389/fcvm.2024.1405606.

    PubMedDOI
  21. 21.
    Stent and Stent-Graft Use in Arteriovenous Dialysis Access. Seminars in interventional radiology. 2016.
    PubMed-indexed articleReview2016

    Stent and Stent-Graft Use in Arteriovenous Dialysis Access. Seminars in interventional radiology. 2016. doi:10.1055/s-0036-1571806.

    PubMedDOI
  22. 22.
    Iatrogenic tibial arteriovenous fistula after Fogarty balloon catheter graft thrombectomy. Clinical case reports. 2021.
    PubMed-indexed articleCase report2021

    Iatrogenic tibial arteriovenous fistula after Fogarty balloon catheter graft thrombectomy. Clinical case reports. 2021. doi:10.1002/ccr3.5050.

    PubMedDOI
  23. 23.
    Cannulation Technique of Vascular Access in Hemodialysis and the Impact on the Arteriovenous Fistula Survival: Systematic Review and Meta-Analysis. Journal of clinical medicine. 2023.
    PubMed-indexed articleMeta-analysis / systematic review2023

    Cannulation Technique of Vascular Access in Hemodialysis and the Impact on the Arteriovenous Fistula Survival: Systematic Review and Meta-Analysis. Journal of clinical medicine. 2023. doi:10.3390/jcm12185946.

    PubMedDOI
  24. 24.
    Advantages of the use of ultrasound in newborn vascular access: a systematic review. Journal of ultrasound. 2024.
    PubMed-indexed articleMeta-analysis / systematic review2024

    Advantages of the use of ultrasound in newborn vascular access: a systematic review. Journal of ultrasound. 2024. doi:10.1007/s40477-023-00832-1.

    PubMedDOI
  25. 25.
    One-stage vs. two-stage brachio-basilic arteriovenous fistula for dialysis access: a systematic review and a meta-analysis. PloS one. 2015.
    PubMed-indexed articleMeta-analysis / systematic review2015

    One-stage vs. two-stage brachio-basilic arteriovenous fistula for dialysis access: a systematic review and a meta-analysis. PloS one. 2015. doi:10.1371/journal.pone.0120154.

    PubMedDOI
  26. 26.
    The Lutonix AV Randomized Trial of Paclitaxel-Coated Balloons in Arteriovenous Fistula Stenosis: 2-Year Results and Subgroup Analysis. 2020.
    PubMed-indexed articleRandomized controlled trial2020

    The Lutonix AV Randomized Trial of Paclitaxel-Coated Balloons in Arteriovenous Fistula Stenosis: 2-Year Results and Subgroup Analysis. 2020. doi:10.1016/j.jvir.2019.08.035.

    PubMedDOI
  27. 27.
    Drug-Coated Balloon Angioplasty for Dysfunctional Arteriovenous Hemodialysis Fistulae: A Randomized Controlled Trial. Clinical journal of the American Society of Nephrology : CJASN. 2024.
    PubMed-indexed articleRandomized controlled trial2024

    Drug-Coated Balloon Angioplasty for Dysfunctional Arteriovenous Hemodialysis Fistulae: A Randomized Controlled Trial. Clinical journal of the American Society of Nephrology : CJASN. 2024. doi:10.2215/cjn.0000000000000359.

    PubMedDOI
  28. 28.
    Comparison of drug-coated balloon angioplasty versus common balloon angioplasty for arteriovenous fistula stenosis: A systematic review and meta-analysis. Clinical cardiology. 2023.
    PubMed-indexed articleMeta-analysis / systematic review2023

    Comparison of drug-coated balloon angioplasty versus common balloon angioplasty for arteriovenous fistula stenosis: A systematic review and meta-analysis. Clinical cardiology. 2023. doi:10.1002/clc.24078.

    PubMedDOI
  29. 29.
    Drug-coated balloon versus conventional balloon angioplasty of hemodialysis arteriovenous fistula or graft: A systematic review and meta-analysis of randomized controlled trials. PloS one. 2020.
    PubMed-indexed articleMeta-analysis / systematic review2020

    Drug-coated balloon versus conventional balloon angioplasty of hemodialysis arteriovenous fistula or graft: A systematic review and meta-analysis of randomized controlled trials. PloS one. 2020. doi:10.1371/journal.pone.0231463.

    PubMedDOI
  30. 30.
    Paclitaxel coated balloon versus conventional balloon angioplasty in dysfunctional dialysis arteriovenous fistula: a systematic review and meta-analysis of randomized controlled trials. Renal failure. 2022.
    PubMed-indexed articleMeta-analysis / systematic review2022

    Paclitaxel coated balloon versus conventional balloon angioplasty in dysfunctional dialysis arteriovenous fistula: a systematic review and meta-analysis of randomized controlled trials. Renal failure. 2022. doi:10.1080/0886022x.2022.2029487.

    PubMedDOI
  31. 31.
    Drug-Coated Balloons for Dysfunctional Dialysis Arteriovenous Fistulas. 2020.
    PubMed-indexed articleRandomized controlled trial2020

    Drug-Coated Balloons for Dysfunctional Dialysis Arteriovenous Fistulas. 2020. doi:10.1056/nejmoa1914617.

    PubMedDOI

Educational use only

AI assists this editorial workflow. Published updates are human-reviewed before publication.

Not intended to diagnose, monitor, predict, prognose, treat, or alleviate disease.

Verify clinically relevant information against primary sources and current guidelines.

AI DisclosurePrivacyTermsCautions