The Art Of Making Your Fistula Or Graft Last

By Lynda K. Ball, MSN, RN, CNN

You have been told that your access is your hemodialysis (HD) lifeline. And, it's true! But each year, some people run out of access sites. Taking steps to keep your fistula or graft healthy and working can help you have a longer, better life with kidney failure.

Learn to Recognize Stenosis

When a vein and an artery are connected by a surgeon, veins are at risk for damage to the lining due to high pressure and blood flow from the artery. This damage can cause a narrow spot in your blood vessel called a stenosis.

Two narrow areas in this mature wrist fistula

Two narrow areas in this mature wrist fistula

Used with permission of Tushar Vachharajani and Fistula First Breakthrough Initiative

The way the body tries to fix this damage is to repair the walls by laying down extra cells. The extra cells leave less and less room for blood to pass through your access. If stenosis is not found early, your access can clot.

Stenosis also occurs in grafts, where it tends to happen more often than in fistulas. Grafts have two "anastomoses" (ends that link to other vessels). One end is linked to an artery. The other end is linked to a vein. The graft material is about 6 mm in diameter and rigid. It is attached to a vein that is smaller in diameter and stretchy. As the high flow/high pressure blood rushes through the graft and into the vein, it can harm the vein wall at the venous anastomosis. A narrow vein at the end of the graft causes blood to back up into your graft and sit, so the access may clot.

Forearm Loop Graft

A central venous stenosis (CVC) occurs in vessels that go from your shoulders across your chest. A CVC stenosis can be caused by:

There are some signs you can look for to see if you might have stenosis:

Prevent Aneurysms in AV Fistulas

Aneurysms with shiny, tight, thin skin showing color change.


Used with permission of S. Glazer, MD

An aneurysm is damage to a blood vessel wall from placing needles into a very small area on your access. If there is very high blood pressure or a stenosis, this pressure can cause the fistula wall to balloon out. As a kid, you may have blown a balloon up so far that it burst. An aneurysm can burst, too. Know what signs to watch for, so a problem site can be fixed in time to save your life:

Scab that will not heal.

Scab that will not heal

Used with permission of S. Glazer, MD

Prevent Pseudoaneurysms in AV Grafts

Pseudoaneurysm – note the shiny, tight, discolored bump with an ulcer on top.


Courtesy of M. Silva, MD

Grafts can have problems that look like those in AV fistulas, but the cause is slightly different. When grafts are cannulated in the same small area, holes form. Blood leaks out and collects into a large bump that looks just like an aneurysm. "Pseudo" means false, so even though it looks like an aneurysm, it is really a huge blood clot (hematoma) that sits on top of the damaged AV graft. The skin over top of this huge bump becomes thin. It can rupture, causing severe loss of blood. Because grafts are foreign material, erosion and infection are other issues to watch for. The most current studies say that AV grafts are the number one access that ruptures. Knowing what to look for and telling your nurse and doctor right away of any changes to your access is vital.

Here are some signs that a pseudoaneurysm needs to be seen by a doctor:

If an access bursts:

  • Press on the site with your fingers NOW. Do not wrap a towel around it, this can pull more blood out of your access.
  • Stay calm. It can keep your heart rate lower so you bleed less.
  • Raise your bleeding arm above your shoulder. This can slow bleeding because blood has to go up hill.
  • Yell for help if someone else is there. Have them call 911.
  • If you are alone, KEEP holding pressure – no peeking. This bleeding won't stop!
  • Call 911

Improve Cannulation Technique

A fistula or graft is made for putting needles in. But, putting them in the wrong way can harm an access. As you can see in this drawing, there are three ways to put needles in a fistula or graft:

  1. Site rotation
  2. Area puncture
  3. Buttonhole technique

Improve Cannulation

Kronung, Dial & Trans, 1984

Of the three, the Area Puncture Technique is the most likely to cause aneurysms. Avoid this! If you rotate sites, it is vital to stay at least ¼" away from the last sites and use the whole length of your access, not just parts. Keep your needle tips at least an inch and a half apart, too. NEVER cannulate aneurysms or pseudoaneurysms because of:

Always use a tourniquet to cannulate a fistula —no matter how big it is, old it is, or how skilled you are. All tourniquets should be placed loosely on your upper arm, above the bicep. But, never use a tourniquet on an AV graft – it is full and firm already and will not stretch any bigger.

Top 5 Reasons to Use a Tourniquet

  1. Prevents vessel damage and infiltration
  2. Gives you more room to cannulate
  3. Puts tension on the vessel wall, for less pain
  4. Firms up the access for assessing
  5. Lets you see the vessel edges

Secure the Needle

Be sure to tape the needles to keep them from falling out and causing hemorrhage.

Not safe taping!

Not safe taping

You need at least three pieces of tape:

  1. Place the first piece of tape over the wings – this stabilizes the needle within the fistula or graft.
  2. The second piece of tape is the "chevron" (V) – this will keep your needle from falling out during HD. Place it sticky side up and cross the tape over the needle tubing and onto the skin.
  3. The third piece of tape should cover the needle puncture site. This will help keep germs from climbing down the needle into your sterile bloodstream.

Extra tape can be used to prevent the needle tubing from being pulled on.

The correct taping technique.

The correct taping technique - 10 The correct taping technique - 10 The correct taping technique - 10

Courtesy of Lynda Ball

You can keep your access safe and healthy when you know what to watch out for. Learn the warning signs and insist on being seen right away if you see a problem.