Hemodialysis Access Creation Maintenance

End-stage renal disease (kidney failure) represents a disease whereby the kidneys can no longer perform their function of filtering the blood to exchange/excrete electrolytes and metabolites. As a result, these products are no longer excreted into the urine but rather built-up in the blood to dangerous levels that cause illness.

The diagnosis of such a condition requires a thorough history and physical examination, as well as proper testing, by a primary care physician and a nephrologist (kidney doctor). The treatment for such a condition requires a way to filter the blood known as hemodialysis, which requires a way to remove the blood so that it can be filtered by a dialysis machine and then returned into the body.

The best way to accomplish this is by the creation of an arterial-venous fistula or AVF. An AVF is created by connecting a vein in the arm to an artery. This allows for the vein, which now sees higher pressure/flow from the artery, to become bigger, stronger, and have faster flow. This, in turn, allows for it to be ‘accessed’ by the dialysis needles on a regular basis without damaging the vein because it is now thicker and stronger. Also, the higher pressure/flow allows for dialysis to be performed in a reasonable amount of time (usually 4 hours). Once created, an AVF usually requires 6-8 weeks to become ready to use, or ‘mature’. If dialysis is needed urgently, however, then a catheter can be placed into a vein at the base of the neck that is tunneled under the skin and exits the upper chest. An AVF can then be created and dialysis can be done through the catheter while the fistula is maturing.

Creation of an AVF and tunneled catheter placement are performed by a vascular surgeon. An ultrasound is required to determine if a suitable vein exists in one of the arms. We perform this ultrasound at our office in our accredited non-invasive vascular lab. Patients can receive this test and be seen by their vascular surgeon at the same visit. If a suitable vein does not exist, then a PTFE graft can be used instead of a vein. Another possible way of performing dialysis is via a peritoneal dialysis catheter, which is placed into the lower abdominal cavity, or pelvis, and exits through a small hole in the lower abdomen. Vascular surgeons also place these catheters.

Once an AVF (or graft) is created, an additional procedure is often required (and sometimes several procedures) throughout the life of the fistula in order to keep it open and running properly. Conditions such as narrowing and aneurysm or blood clot formation can prevent the AVF from working properly and can threaten its patency (ability to stay open). For this reason, additional ultrasounds of the AVF are often required and if such a condition is found, then the vascular surgeon can usually fix the problem with a catheter-based procedure using a balloon and/or stent. Sometimes, additional open surgery is required.