What is dialysis access surgery?
Dialysis, either hemodialysis or peritoneal dialysis, is a life-saving
procedure that replaces kidney function when the organs fail. In order to
be treated with dialysis, physicians must establish a connection between
the dialysis equipment and the patient's bloodstream. Dialysis access
surgery creates the vascular opening so a needle can be inserted for
hemodialysis or an abdominal catheter inserted for peritoneal dialysis.
There are several ways to establish dialysis access. Your nephrologist
(kidney doctor) and surgeon will work with you to decide which type of
access will provide you with the best long-term dialysis.
Who performs the dialysis access procedure?
Establishing dialysis access is an invasive (surgical) procedure that can
be performed by nephrologists, interventional radiologists and surgeons. A
team effort helps ensure excellent patient service, care and long-term
results. The dialysis access center at BIDMC is staffed with leading
nephrologists, interventional radiologists and transplant surgeons in the
Boston community. The team also consists of a dialysis access nurse
coordinator and social workers. We meet regularly to ensure that you
receive the best care each specialty has to offer.
What type of dialysis access procedure is necessary for hemodialysis?
Hemodialysis circulates blood through a machine outside of your body to
remove toxins and excess fluid and to correct electrolytes like potassium,
sodium, phosphate and calcium, to name a few. The machine then pumps the
cleansed blood back into your body. The blood leaves and returns to the
body through a catheter, a long piece of silicone tubing placed in the
neck, chest or leg. A catheter is used to establish quick vascular
(bloodstream) access if you need to begin dialysis therapy immediately. Or
dialysis access nurses can access the bloodstream by placing two needles
into a fistula or a graft that has been previously created for this
How are catheters placed?
Catheters come in two varieties, temporary and permanent. Temporary
catheters penetrate the skin and directly enter the venous system.
Permanent catheters also penetrate the skin, but are then tunneled under
the skin for several inches before they finally enter the venous system.
Tunneling the catheter reduces the risk of infection.
Any medical professional can place a temporary catheter using a local
anesthetic and minimal sedation to help with minor discomfort. However for
placement of permanent catheters, a surgeon in the operating room, or an
interventional radiologist in the interventional suite is necessary. During
the procedure, physicians use fluoroscopy (continuous X-rays) to be sure
the catheter is positioned correctly. Permanent catheters require a minor
procedure for removal whereas temporary catheters can simply be pulled out.
Are catheters safe for long-term use?
Prolonged catheter access can lead to multiple complications, the most
common of which is infection. Even with excellent placement technique,
bacteria can enter the bloodstream directly through the catheter during
dialysis. Bacteria from the skin can also move down the catheter and enter
the bloodstream. With catheter infection people develop high fevers and
chills and need prompt treatment. Generally physicians must remove the
catheter so the body can fight the infection.
Another possible complication from long-term catheter use is damage to the
main chest vessels, which can lead to stenosis (narrowing) or thrombosis
(clotting) of the veins. This type of damage is usually permanent and the
vessel - as well as the arm on the side of the vessel - may no longer be
useable for dialysis access.
Because of these potential complications, physicians make every effort to
avoid prolonged catheter use.
What is an AV fistula?
The best way to establish long-term hemodialysis access is to construct an
arteriovenous (AV) fistula. An AV fistula is a surgically placed "shunt";
that is, an artery is directly sutured to a vein. An artery is a
high-pressure vessel that carries blood away from the heart and delivers
nutrients and oxygen to the tissues. A vein is a low-pressure vessel that
returns blood back to the heart to begin the process all over again.
When an artery and a vein are sewn together, the high-pressure blood does
not reach the tissues but is diverted instead into the vein and back to the
heart. Over time the vein will dilate, carry more blood and become
stronger, a process that is often called maturation. At maturation, nurses
can easily access the vein with needles for dialysis therapy.
Where are AV fistulas located and how long do they last?
Surgeons can create an AV fistula in your wrist, forearm, inner elbow or
upper arm. When properly constructed, and with satisfactory maturation, an
AV fistula can function for many years.
How is the AV fistula procedure performed?
A surgeon usually performs the procedure in the operating room. You receive
a local anesthetic (numbing medicine) at the proposed site along with IV
sedation to relax you. Discomfort is minimal and you may even fall asleep
during the 1 to 2 hour-long procedure. The surgical incision is usually
only 2 to 4 inches long. Generally you are able to return home later that
same day. The fistula usually requires from 8 to 12 weeks for the veins to
dilate prior to initial use.
Despite excellent technique, some patients may suffer complications from
the AV fistula procedure. Infection, bleeding, arm swelling and/or tingling
in the fingers may occur postoperatively. An unusual, but serious,
complication can occur when the arterial blood that is supposed to reach
the hand is redirected through the fistula. Sometimes the fistula functions
so well that not enough blood reaches the hand causing ischemia (lack of
oxygen). This condition is called "steal" and usually requires surgical
procedure to establish a new access at a different site.
Can anyone have an AV fistula?
Unfortunately not every patient is suitable for an AV fistula. Numerous
needle sticks for IV fluids, blood work and/or medicines can damage veins
over time, creating scar tissue, which can make creation of an AV fistula
impossible. If the veins are damaged or too small, the AV fistula will not
mature, or worse yet, clot. In this situation, the dialysis access team
recommends other options that may include another fistula at a different
site, catheter placement or an arteriovenous graft.
What is an arteriovenous graft?
An arteriovenous graft is another form of dialysis access, which can be
used when people do not have satisfactory veins for an AV fistula. In this
procedure, surgeons connect an artery and a large vein in your elbow or
armpit using a graft made of synthetic fabric that is woven to create a
watertight tube. The graft is frequently used to repair blood vessels or
perform blood vessel bypass when blockages occur, and also works very well
to establish dialysis access.
How is the AV graft created?
Creating an AV graft is a surgical procedure, which requires a small
incision at the proposed site. Surgeons sew the graft to an artery and
tunnel it, just under the skin, creating a loop back to the starting
incision where it is then sewn to a vein. The long loop gives the dialysis
nurses space to access the graft. AV grafts can be safely used in about two
weeks, as no maturation of the vessels is necessary. Grafts have a lifespan
of approximately 2 to 3 years but can often last longer. However, AV grafts
can be more troublesome than AV fistulas. Blood is more likely to clot in
grafts because they are made of prosthetic (foreign) material. When this
happens, interventional procedures can remove the clot and restore blood
flow for dialysis.
Complications related to AV grafts are similar to those with AV fistulas:
bleeding, thrombosis (clotting), steal and because of the prosthetic nature
of the graft, infection. Infected grafts must be removed immediately and a
new access site developed once the infection clears.
What type of dialysis access procedure is necessary for peritoneal
Surgeons must place a long silicone-based tube called a Tenckhoff catheter
into the abdomen before peritoneal dialysis can begin. The surgeon in the
operating room positions the tube using a local anesthetic and IV sedation.
Making a small incision in your abdomen, the surgeon advances the tube deep
into the lower part of your peritoneal cavity (the membrane lining the
inside of the abdomen), tunnels the tube under the skin for several inches,
brings the tube up through the skin at a different location, and then
surgically closes the initial incision. A sterile dressing covers the
catheter that remains outside of the body.
Tunneling the catheter reduces the likelihood of infection in the
peritoneal cavity. You may be allowed to go home the same day of surgery.
Peritoneal dialysis can begin when the incisions heal, usually about 2 to 4
weeks after the access surgery.
What types of complications are possible from the Tenckhoff catheter?
Complications related to catheter placement may include bleeding and damage
to large or small intestines or abdominal blood vessels. Although unusual,
these issues could require additional corrective surgery. Once peritoneal
dialysis begins, complications related to repeated use of the catheter
include peritonitis, which is an infection of the peritoneal cavity.
Peritonitis, which can be quite serious, is usually associated with
abdominal pain, fevers and cloudy peritoneal dialysis solution. If the
infection does not respond to antibiotic treatment, then it may be
necessary to remove the catheter.
When should dialysis access surgery take place?
The best approach is to undergo dialysis access surgery well before
dialysis therapy needs to begin, which will give the access site time to
mature and avoid the use of temporary catheters. You may need a temporary
catheter while you are waiting for your permanent AV fistula or AV graft to
How does the dialysis access team evaluate individuals for long-term
Our team, which includes a nephrologist, interventional radiologist,
surgeon and dialysis access coordinator, perform an extensive physical exam
to identify satisfactory vessels to construct the AV fistula or graft. We
may request additional studies such as ultrasounds or even dye studies of
the blood vessels in your arms and legs. After we decide on the appropriate
type of access, we select the location. Typically surgeons construct
hemodialysis access in the forearm of your non-dominant hand. If this site
is not suitable then we may choose to use the forearm of the dominant hand
or the upper arm of your non-dominant hand, above the elbow.
Whom do I call for more information?
For more information about the Transplant Institute at Beth Israel
Deaconess Medical Center, please call 617-632-9700.