One of the most important things you’ll decide about your hemodialysis treatment is what type of access you’ll have. Hemodialysis access is the way you reach your blood for hemodialysis. To allow blood to flow from you to the dialyzer and back, you need a large blood vessel with good blood flow. To create a vessel that is large enough, an access to your blood is formed with outpatient surgery, usually in your arm or leg.

Choosing your access is a decision that you and your doctor should make early in your treatment. It will take several weeks to a few months for your access to heal or ‘mature’ and be ready to use for dialysis.

The preferred type of permanent access is a fistula. Until your permanent access is ready, you may have a catheter (a hollow tube, part of which goes outside your body) as a temporary access. The catheter would be placed in your neck, just below your collarbone, or in a large vein in your groin.

On this page, you will learn more about the types of hemodialysis access and their pros and cons. This information should help you with your decision. Ultimately, you will work with your care team to decide which access option is best for you.

Arteriovenous (AV) Fistula

What is an AV Fistula?

A fistula is formed under the skin by sewing a vein to an artery, often in your forearm. Strong arterial blood flows through the vein and makes it larger. A larger vein can provide the high flow rates that are needed to clean the blood. For the surgery, you’ll be given a local anesthetic and most of the time; it can be done on an outpatient basis.

Who should use a fistula?

A fistula is the best type of access for hemodialysis. Fistulas last the longest (sometimes decades) with the fewest problems. They are the least prone to infection and clotting. Most people can have a fistula. You may be told that your veins are too small or too weak for a fistula. This may be true, especially if you have diabetes or vascular disease. But if a surgeon tells you that you can’t have a fistula, you can ask for a second opinion. You can also ask for vessel mapping - an ultrasound test that looks at the vessels under the skin to see how large and strong they are. If you can’t have a fistula, there are other options.

How long before the fistula is ready for use?

The process of the fistula becoming strong and large enough to be used in hemodialysis is called maturing. In general this takes four to twelve weeks. You can do some easy exercises to help the fistula mature.

What are the pros and cons of a fistula?

Pros

• Less chance of infection than other types of access
• Less chance of clots forming than other types of access
• Usually work for many years - sometimes decades
• Usually need fewer “tune-ups” (revisions) to repair
• Can use the Buttonhole Technique for needles

Cons

• Visible on your forearm
• May take time to develop

Arteriovenous (AV) Graft

What is an AV graft?

A graft is created under the skin by connecting an artery and a vein with a synthetic vein, usually in your arm.

Who should use a graft?

If you have small blood vessels that won’t develop into a fistula, a graft may be a good option for you.

How long before the graft is ready to use?

A graft doesn’t need to develop, like a fistula does, but it does need time to heal. It is often ready for use in hemodialysis in two to three weeks.

What are the pros and cons of a graft?

Pros

• Does not have to ‘mature’ like a fistula, so it can be used with a few weeks after surgery
• Permanent access option if a fistula won’t work

Cons

• Has a higher risk of clotting than a fistula has
• Has a higher risk of infection than a fistula has
• A graft doesn’t last as long as a fistula (a few years at most)
• Most grafts need “tune-ups” (revisions) in the hospital one or more times a year
• Is visible on forearm

Central Venous Catheter

What is a central venous catheter?

A central venous catheter is inserted into a vein in your neck, chest, or leg (near the groin). It has two tubes to allow the two-way blood flow needed for hemodialysis. The tubes are connected to the catheter. Catheters have an exit site, so they require a bandage or dressing to cover them. It is important to keep the dressing and catheter clean and dry all the time. This may mean that showers are not allowed, and you need to take tub baths or sponge baths.

Who should use a central venous catheter?

Often, a central venous catheter is used as a temporary access option for people who cannot wait for their fistula to mature or their graft to heal before they need hemodialysis. They are most often used for up to three weeks. For some patients who can’t have a fistula or graft (e.g., they have run out of access sites), long-term catheter access is needed. In this case, a cuffed, tunneled catheter is used. The catheter is tunneled under the skin, and a fibrous cuff holds it in place and helps keep out bacteria.

How long before the central venous catheter is ready to use?

Catheters can be used for hemodialysis as soon as it is placed.

What are the pros and cons of a venous catheter?

Pros

• Once the catheter is placed, no needle contact for the patient
• Can be used right away for hemodialysis

Cons

• There is a very high risk of clotting
• There is a very high risk of life-threatening blood infections
• May cause narrowing of the vein in which it is placed, which makes future permanent access on that side of the body less likely
• Catheters may need to be changed often
• Blood flow rates are lower, so longer treatment times might be necessary
• You can’t get the catheter wet, so swimming is off-limits and showers may not be possible

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