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Last Updated 03/08/20

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Hemodialysis requires frequent access to the patient's blood stream (vascular system). Vascular access has been called the "Achilles' Heel" of hemodialysis care. Hemodialysis vascular access procedures and associated costs come to $8,000-10,000 per patient per year. This amount represents approximately 25 percent of total ESRD medical costs. The most common problems are stenosis (narrowing of graft/blood vessel), infection, and thrombosis (clotting).

At present, three types of vascular access are predominant: AV (arteriovenous) fistulas, AV grafts, and catheters. AV fistulas are surgically created by connecting a patient's own artery and vein, usually in the forearm. AV fistulas have the lowest rate of complications, but take from several weeks to several months to mature, heal, and develop in size. Over time, an AV fistula becomes large enough to accommodate the needles required for hemodialysis. AV grafts are also created surgically, but use a synthetic blood vessel to connect the vein and artery. The needles are inserted into this synthetic graft. AV grafts require shorter times (if any) to heal before they can be used, but tend to have more incidents of stenosis and thrombosis than AV fistulas. Catheters are most often used as "bridge" devices, used to bridge the time between from start of dialysis treatments (often an emergency) to when the patient's AV fistula or AV graft has matured and is ready for use. Catheters are generally not used as long-term devices as they tend to have higher rates of infection and thrombosis.

Warning:  Changes should never be made in a patient's treatment or care based solely on the information found here.  Every patient has unique healthcare concerns and considerations and all these factors must all be taken into account before any changes can be safely made.  All medical and therapeutic decisions must come from a qualified health care provider.  Read RenalWEB's Legal Disclaimer before proceeding.


Delayed Conversion from Central Venous Catheter to Non-Catheter Hemodialysis Access Associates with an Increased Risk of Death: a Retrospective Cohort Study Based on Data from a Large Dialysis Provider - Free, full-text, Early View article from Hemodialysis International. - March 5, 2020


Buttonhole Cannulation of Arteriovenous Fistulas: a Dialysis Nurse’s Perspective - (5-page pdf) Free, full-text, Early Access article from Kidney360. - March 5, 2020


Patterns of Opioid Use in Dialysis Access Procedures - Article in Press abstract from Journal of Vascular Surgery. - February 27, 2020


Fist Assist Helps Prep Vein for Dialysis Surgery, Lead to Healthy Fistula - Article from MedGadget. - February 26, 2020

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blueball Latest Scientific Journal Articles on Vascular Access
Latest issue of the Journal of Vascular Surgery
Cannulation of the Arteriovenous Fistula (AVF) video from the Network Coordinating Center (NCC) web site
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Catheter Reduction Toolkit - Resources from the National Forum of ESRD Networks web site

Change Concepts from Fistula First Catheter Last

A Clinical Discussion of AV Fistula and AV Graft Complications: Part 1 and Part 2 - Posting from the Renal Fellow Network blog. 


Clinical Exam of Hemodialysis Vascular Access - Washington University Nephrology Webisode - Video from the Renal Fellow Network blog

Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases Society of America - full-text article from Clinical Infectious Diseases. - July 1, 2009
Creating AV Fistulas in All Eligible Hemodialysis Patients from the University of Oklahoma College of Medicine web site
Dialysis Access from the VascularWeb web site

Dialysis Audit Tools: Includes pdfs for hemodialysis hand hygiene, catheter connect/disconnect, exit site care, and AV fistula/graft decannualationfrom the Dialysis Bloodstream Infection (BSI web page) Prevention Collaborative

Video: Dialysis Patients Speak: a Conversation about the Importance of AV Fistulas - 12-minute video on YouTube produced in 2005 for the ESRD Network of New England. - December 13, 2012


The New European Renal Best Practice Guideline on Arteriovenous Access: Why Worthwhile to Read? - Free, full-text, Advance Article from NDT. - June 2019

Fistula First Catheter Last web site, Fistula First Data, and Patient Section
Fistula First: Patient Educational Materials - from the ESRD NCC web site

Free, Full-Text Articles from Canadian Journal of Kidney Health and Disease - September 27, 2016

Guidelines for the Prevention of Intravascular Catheter Related Infections from Morbidity and Mortality Weekly Report web site - August 2002

Hemodialysis Access 101 - Online Learning Module from Namrata Krishnan at Yale School of Medicine. - 2018


How to Examine a Vascular Access - Posting from the Renal Fellow Network blog. 

Part 1 The Basics
Part 2 The Physical Exam

Just the Facts: Vascular Access and Información esencial: Acceso vascular (pdf format requires Adobe Acrobat Reader) from the Life Options web site
Keeping Your Access Uncovered - (2-page pdf) from the Northwest Renal Network
The natural history of autologous fistulas as first-time dialysis access in the KDOQI era - full text article from the Journal of Vascular Surgery - February 2008
Please be careful with my veins - An information page to be given to nurses or phlebotomist who are about to start an IV or draw blood on dialysis patients (1998). All information from the Nephron Information Center web site.
Revised European Best Practice Guidelines for Hemodialysis - Vascular Access - guidelines endorsed by the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA)
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Save Your Vein - 2-minute video from Kidney Care UK.

Self-Cannulation - Video via Renal Fellow Network web site

blue ball Vascular Access from the Northwest Renal Network web site
Vascular Access - A Lifeline for Dialysis - new module at the KidneySchool™.
Vascular Access, Cannulation and Care: A Nursing Best Practice Guide for Arteriovenous Fistula - (pdf) from the EDTNA/ERCA
Vascular Access Fact Sheet (pdf format requires Adobe Acrobat reader.) from the American Nephrology Nurses’ Association
Vascular Access for Hemodialysis from the NIDDK Publications Online for Kidney Disease

Vascular Access POC Algorithm - Tool (1-page pdf) from ESRD Network 11

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Vascular Access: 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS) from European Journal of Vascular and Endovascular Surgery. - June 2018

blue ball Vital Signs: Central Line--Associated Blood Stream Infections --- United States, 2001, 2008, and 2009 - Article from the CDC's Morbidity and Mortality Weekly Report. The article mentions the word "dialysis" 42 times. - March 2011
"The majority of central line--associated blood stream infections are now occurring outside of ICUs, many outside of hospitals altogether, especially in outpatient dialysis clinics."

Want To Learn about Hemodialysis Access? Here's "Hemodialysis Access 101"! - Posting from the Renal Fellow Network blog. - August 28, 2018

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  PUBMED SEARCHES (National Library of Medicine's MEDLINE Database)
vascular access and hemodialysis articles   Continually Updated!
catheter AND hemodialysis articles   Continually Updated!
anticoagulants AND catheter AND hemodialysis articles   Continually Updated!
graft survival AND hemodialysis articles   Continually Updated!
cost AND access AND dialysis Continually Updated!
MEDLINE / Pubmed Information from the National Library of Medicine
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K/DOQI™ -  Kidney Disease Outcomes Quality Initiative ( pronounced "kay DOE key" )

Clinical Practice Guidelines for Vascular Access 2006 Updates

I. Clinical Practice Guidelines for Vascular Access

Guideline 1. Patient Preparation for Permanent Hemodialysis Access
Guideline 2. Selection and Placement of Hemodialysis Access
Guideline 3. Cannulation of Fistulae and Grafts and Accession of Hemodialysis Catheters and Port Catheter Systems
Guideline 4. Detection of Access Dysfunction: Monitoring, Surveillance, and Diagnostic Testing
Guideline 5. Treatment of Fistula Complications
Guideline 6. Treatment of Arteriovenous Graft Complications
Guideline 7. Prevention and Treatment of Catheter and Port Complications
Guideline 8. Clinical Outcome Goals

II. Clinical Practice Recommendations for Vascular Access

Clinical Practice Recommendations for Guideline 1: Patient Preparation for Permanent Hemodialysis Access
Clinical Practice Recommendations for Guideline 2: Selection and Placement of Hemodialysis Access
Clinical Practice Recommendations for Guideline 3: Cannulation of Fistulae and Grafts and Accession of Dialysis Catheters and Ports
Clinical Practice Recommendations for Guideline 4: Detection of Access Dysfunction: Monitoring, Surveillance, and Diagnostic Testing
Clinical Practice Recommendations for Guideline 5: Treatment of Fistula Complications
Clinical Practice Recommendations for Guideline 7: Prevention and Treatment of Catheter and Port Complications
Clinical Practice Recommendation 8: Vascular Access in Pediatric Patients



The ESKD "Life-Plan: A New Concept In The NKF Vascular Access Guideline Update - Posting from the KidneyViews blog. - December 2019

K/DOQI Home Page from the National Kidney Foundation web site
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Vascular Access Issues on RenalWEB
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Listing of Vascular Access Society meetings and events
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E-mail to RenalWEB on the Vascular Access Topic
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