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Haemodialysis vascular access — fistula, graft and complications

The preferred dialysis access is an autologous arteriovenous fistula, in the non-dominant arm, starting distally and moving proximally — radiocephalic, then brachiocephalic, then brachiobasilic with transposition, and only after them a graft; it is planned months before dialysis starts, arm veins are preserved, and complications such as stenosis, thrombosis and steal syndrome are recognised early.

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Why it matters in the exam

The exam asks about the order of choice, timing and complications. Referral to a vascular surgeon is made when eGFR falls below 30 and access is planned when dialysis is expected within about half a year, because a fistula needs about 6–8 weeks or more to mature. Before surgery veins and arteries are mapped by ultrasound (a vein of at least 2–2.5 mm and an artery of at least 2 mm). In a patient with chronic kidney disease the veins of the non-dominant arm are preserved — no PICC and no blood draws from them. The traditional "rule of 6" for a mature fistula: flow above 600 mL per minute, diameter above 6 mm, depth less than 6 mm, and within 6 weeks. A prosthetic graft (AVG) is ready for use sooner (2–4 weeks, and some grafts within days), but is more prone to infection and thrombosis, and needs more interventions.

Complications: stenosis — in a graft mainly at the venous anastomosis from intimal hyperplasia; thrombosis — treated by clot removal and correction of the stenosis that caused it; infection — more common in a graft and sometimes requiring its removal; and steal syndrome (DASS) — a cold, painful hand sometimes with ulcers, mainly with brachial artery-based access, in older and diabetic patients. In severe steal the treatment is surgical, for example DRIL (distal revascularisation with interval ligation), or flow reduction when flow is high. A special emergency is ischaemic monomelic neuropathy — sudden pain and weakness of all hand nerves immediately after creating a brachial access — which requires immediate closure of the access. Further complications: high-output heart failure, aneurysms in the arm, and swelling of the whole arm from central vein stenosis (usually after central catheters). On examination: a healthy fistula collapses when the arm is raised; a fistula that stays tense and pulsatile suggests outflow stenosis.

A central dialysis catheter is a temporary solution only, given its high rate of infection and of central vein stenosis.

Key points

• Autologous fistula is preferred.
• Distal to proximal, non-dominant arm.
• Referral when eGFR is below 30.
• Rule of 6 for a mature fistula.
• Cold, painful hand — steal syndrome.

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Sources

• KDOQI Clinical Practice Guideline for Vascular Access, 2019 — Access planning, creation and complications
• ESVS Clinical Practice Guidelines: Vascular Access, 2018 — Recommendations
• Rutherford's Vascular Surgery and Endovascular Therapy, 10th edition (2022) — Hemodialysis access

Sources are given for further reading; the text is written afresh and not copied from them.

Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.