Haemodialysis Access
Date issued: October 2023
Review date: October 2025
Ref: B-494/JM/Renal/Haemodialysis Access
PDF: Haemodialysis Access final October 2023.pdf [pdf] 735KB
This booklet aims to tell you more about:
-
Vascular Access for you when you have chosen haemodialysis
-
What a Fistula is and why you require it
-
Alternative access to a Fistula
-
Before, during and after the surgery
-
How you can care for your Fistula
-
Possible Complications you may encounter
-
Who you can contact
What is a Fistula?
A Fistula (Arteriovenous Fistula) is the joining of an artery and a vein to create a big blood vessel in your arm to enable needles to be put into your arm in order to be able to get enough blood flow in and out for you to have haemodialysis.
This is usually created at your wrist or your elbow preferably in your hand that you use the least. On rare occasions a fistula may need to be created in one of your legs.
Why do I need a Fistula?
In order for you to have haemodialysis we need to get access to your blood stream so that the dialysis machine can clean your blood. The best way of doing this is to create a fistula, as they tend to last longer than other forms of access and often have fewer complications.
Before having a Fistula
Before you can have a fistula formed, you would need to have an ultrasound scan (mapping) of the vessels in your arm to see if there are any vessels suitable to make a fistula. This is normally requested when your eGFR is 16 or below.
Your non-dominant arm would normally be scanned first and this usually takes place in the Vascular Assessment unit on Level 4 at Derriford Hospital.
The scan itself usually takes around 15 minutes but on occasion we do request that both of your arms are scanned and so this can take a little longer.
Once we have the report back which identifies if your vessels are suitable we would normally advise you not to have any blood pressures or blood tests taken on this arm so that the vessels are protected.
At this point, we would give you a wristband that you can wear so that it reminds other healthcare professionals not to use this arm.
What happens if my vessels aren’t suitable?
If the scan identifies that none of your vessels are suitable then we may request for you to have a repeat scan after a few months or failing this, we may request that you are seen by a Vascular Surgeon to assess your arms and possibly your legs which will involve a further scan.
There are alternatives to a fistula which are detailed below:
Arteriovenous Graft - Joining an artery and a vein by a synthetic piece of tubing (prosthetic graft) which can be needled similarly to a fistula. This can be inserted into either your arms or your legs.
Other Forms of Vascular Access
Tunnelled Line - A tunnelled line is a plastic tube inserted into one of the large veins in the neck that leads into the heart. This allows blood to be removed, cleaned and returned via the dialysis machine.
Although this is a way of getting blood out of the body, as it involves a foreign object there are increased risks of infection and there are sometimes complications with tunnelled lines therefore it would be better for you to have a fistula or graft.
Before The Operation
Once your vessels have been identified as being suitable we normally ring you to discuss putting you on the waiting list for a fistula. Once you are on the waiting list, it can approximately 8 weeks for you to be contacted regarding a date for the operation.
When a date becomes available, one of the Chronic Kidney Disease Nurses will phone you to discuss this with you. Depending upon which vessels are suitable for a fistula will depend on how the operation is done, either under general or local anaesthetic.
You will then receive some information from the secretaries about your admission which will inform you of the time and place that you need to arrive. Usually this involves going to Fal ward on level 4 often for around 7am.
The Operation
Wrist (Radiocephalic) and Elbow (Brachiocephalic) level fistulas are usually created under a local anaesthetic which is performed as a day-case procedure. This means that as long as you are feeling well afterwards, that you can go home after a bit of recovery time.
Local anaesthetic doesn’t require you to be nil by mouth before the operation, but we recommend just having a light breakfast prior to the procedure. This procedure takes approximately 60 minutes and afterwards you are taken to Postbridge Ward to recover and have some refreshments prior to going home.
The more complex fistula, in the upper arm (Brachiobasillic), is created under a general anaesthetic which involves attending a pre assessment clinic first. This is where you will be seen by an anaesthetist to discuss the general anaesthetic.
The Operation
General anaesthetic involves being nil by mouth before the procedure. You will be asleep during the procedure and because of this you will need to be monitored for 24 hours so normally you would be taken to Mayflower, the Renal Ward, after the operation to recover. As long as you are feeling well, you will be discharged the day after the procedure.
During the surgery, the skin of the arm will be cleaned with antiseptic once you have had the general anaesthetic or before the local anaesthetic is injected. A small cut is made into the skin and once the artery and vein have been found they are sewn together. Lastly, the skin is sewn back together again.
The operation takes place in an operating theatre and is performed by a vascular surgeon.
Care of your Fistula After the Operation
Your fistula will be checked by a nurse for a buzzing sensation known as a "thrill" which can be detected by feeling the area. They will also listen for a "bruit" around the operation site, which is a whooshing sound heard through a stethoscope. These sounds are caused by high flow of blood through the vein and indicate that the fistula is working.
You will need to keep the operation site clean and dry until the wound edges have healed. You will be provided with some dressings to go home with.
Approximately 1 to 2 weeks after the operation, we will invite you to attend the outpatient department so that we can check your fistula and review the wound. We will then request a further scan to assess the flows through the fistula around 4 to 6 weeks after the operation. Your fistula should be ready to use approximately 8 weeks after it has been created.
Long Term Care of your Fistula
There are a few things which you can do to help look after your fistula has been formed:
|
DO |
DO NOT |
|---|---|
|
Exercise your hand regularly. Squeezing a soft ball for five minutes twice or three times a day increases blood flow through the fistula. |
Do not wear tight fitting clothes or bracelets or watches on your fistula arm. |
|
Check your fistula daily. If it becomes red or tender, contact the hospital. If the thrill has changed or disappeared, contact the hospital immediately. |
Do not use your fistula arm for carrying/lifting heavy objects. |
|
Check your hand. |
Never let any body take blood tests, insert drip or measure blood pressure on your fistula arm. |
Possible Complications
Clotting - there is a risk that a clot can form in your fistula and cause it to stop working. It is important that you check the fistula regularly and if you notice a change in how it feels, contact the unit as soon as possible as sometimes the clot can be removed by interventional radiology.
Infection - occasionally infections can occur at the fistula site and this may need treating with antibiotics. If you notice pain or redness around the site please contact the unit.
Steal Syndrome - this condition occurs when the fistula takes away some of the blood supply from your hand. It can result in a painful or cold hand. A glove can be worn to relieve this but if it becomes troublesome, surgery may be required.
Possible Complications
Neuropathy - your fistula can divert blood away from the nerves in the arm, which may cause a tingling sensation in the hand.
Bleeding - Although bleeding is uncommon, it is important that if you start bleeding from the fistula that you apply pressure over the area immediately. Always contact the unit if you have had any bleeding from the site or if you think there is an abnormal swelling or sensation within the fistula. Bleeding can be life-threatening and therefore you must seek medical attention straight away.
Swelling - Mild swelling is expected after surgery and should settle within days. Raising your arm while in bed may help. Severe or continuous swelling of the whole arm may be due to narrowing of one of the veins taking blood back to the heart. If you develop this, you should contact the unit.
Useful Contacts
CKD Team
You can contact us on the below number Monday to Friday 8am to 4pm. If your query is not urgent please leave a message and we will get back to you.
01752 430310
For any urgent queries out of hours please contact: Mayflower Ward, 01752 431485
Once you commence haemodialysis please contact the dialysis unit:
- Plymouth Dialysis Unit - 01752 431700
- Kingsbridge Dialysis Unit - 01752 438250
- Holsworthy Dialysis Unit - 01626 923807
- Saltash Dialysis Unit— 01752 278451
