Access care

Fistula care

Your fistula is your lifeline and you can play an active role in keeping it in good condition. There are many things you can do in your daily life as well as during treatment to contribute to your long-term well-being and to make sure dialysis can be performed without complications. All of them are simple – just let them become a part of your daily routine.

Of course every patient's fistula is different and may require different care. Please discuss with your healthcare team what is right for you – we are here to give you all the advice and support you may need.

Why do you need a fistula

Our blood vessels are not well suited to providing a sufficient and constant blood flow for dialysis. We have two types of blood vessels: veins and arteries. Our veins are located just beneath the skin and we can often see them with the naked eye. They can be punctured quite easily, but the blood flow in veins is too low for dialysis treatment.

In the arteries, blood flows with a higher pressure than in the veins, but they are “hidden” much deeper under the skin, and are hence much more difficult to puncture. Furthermore, arteries have a very strong pulse and high pressure, which is not ideal for dialysis treatment. Therefore we need a special blood vessel called fistula.

A fistula is created during a short surgical intervention by joining an artery with a vein – that is why it is called “arteriovenous”. Fistulas are usually located in the forearm. The newly created blood vessel combines the properties of arteries and veins: the blood flow and blood pressure is higher than in a vein and the blood vessel has a palpable thrill, similar to what you can feel when touching an artery.

During the maturation process the diameter of the blood vessel grows making it easier to insert a needle, and the wall thickness of the fistula increases. This “maturation process” usually takes two to six weeks. After maturation the fistula can be cannulated, as it allows a high amount of blood to flow into the extracorporeal blood circuit, enabling effective haemodialysis.

Arteriovenous fistula: combining the characteristics of an artery and a vein

"Arterio" comes from artery, which is a blood vessel that carries fast-flowing blood that is rich in oxygen from the heart to the tissues in the body
"Venous" comes from vein, which is a blood vessel that carries the blood away from the tissues back to the heart to collect more oxygen from the lungs
"Fistula" refers to a connection between two blood vessels that normally do not connect

Fistula Check

Given that the fistula plays a key role in a successful dialysis treatment, it is really important to keep it in good condition. Your fistula needs checking every day! You should use your eyes, ears and fingers to check that everything is OK.

[Translate to UK - englisch:] Man checking his fistula arm

When looking at your fistula arm, be aware of any signs of redness or swelling.

One way to check if there is a good blood flow through the fistula is to use a stethoscope in order to hear a sound called “bruit”. Ask your dialysis team to show you how to do this.

The easiest way is to put your hand on your fistula. You should feel a rhythmic vibration / buzzing sensation called a “thrill”. When palpating your fistula, pay special attention if it feels sore or warmer than usual.

Please follow a couple of simple rules to minimise the danger of infection or thrombosis, which are the most common dangers for your fistula:

Let the blood move freely

Avoid pressure of any kind on your fistula arm, as it can lead to thrombosis, especially in a condition of low blood pressure. You should avoid the following:

Wearing tight clothing or restricting objects such as watches or bracelets which could cause a compression of the fistula.
Sleeping on your access arm, as it can lead to transitory fistula kinking and a reduction of the blood flow.
Strong bending of your fistula arm.
Measuring your blood pressure in the fistula arm with a blood pressure meter, as inflating the cuff induces a compression of the blood vessels.
Drawing blood or injections, as afterwards haemostasis has to be performed. In addition, unqualified personnel could potentially damage the fistula.

If you notice any of these disturbing symptoms: redness, swelling, soreness, increased temperature in the fistula area, please contact your doctor or dialysis team immediately.

Keep it clean

[Translate to UK - englisch:] Man washing his arm

In order to avoid any possible bacteria migrations from the skin to the blood circulation system, which could lead to infection, always remember to:

Wash the access site with water and soap reserved for that purpose only every day and before each dialysis session.
Avoid coughing or sneezing in the direction of the fistula.
Refrain from scratching the fistula area and particularly the access sites.

Protect it from injuries

[Translate to UK - englisch:] Man riding a bicycle

Avoid activities that might cause injuries to the fistula such as lifting heavy objects like suitcases or packing cases. For instance, when shopping take a trolley instead of a basket and don’t use your fistula arm to carry your heavy grocery bags home.
Do sports which do not over-burden your fistula arm, for example jogging or cycling.

Be careful of temperature extremes

[Translate to UK - englisch:] Ice and sun as symbols for extreme temperatures

Very high or low temperatures can also have adverse effects on your fistula and lead to thrombosis. It is recommendable not to expose yourself to:

Excessive heat (e.g. sauna or sweat baths), as it induces vessel dilation and reduces the blood pressure and blood flow. If you want to be outside on a very hot day, try to stay in the shade.
Excessive cold. This induces vessel constriction and with it reduced blood flow in the limbs, especially in the fistula arm. On extremely cold days, remember to wear appropriate warm clothes if you want to get some fresh air outside.

Central venous catheter (CVC) care

The central venous catheter, a special type of intravenous catheter (tube), is indispensable in today’s dialysis centres. Some patients start haemodialysis without permanent vascular access – they will most often have a central venous catheter (CVC).

Why do you need a CVC

If a patient’s blood vessels are damaged or very fragile, it is not possible to create a fistula. And because access is so fast, CVCs are also used for emergency treatment. If a central venous catheter is the best choice for your haemodialysis treatment, a physician or surgeon will insert it into a central vein – a jugular vein (neck), a subclavian vein (chest), or a femoral vein (groin).

Central venous catheters offer immediate access to the blood system. Patients with CVCs may appreciate that they can move their arms and hands freely during dialysis, and that needle sticks are avoided. However, a long-term complication of catheters – especially those placed in the subclavian vein – is that the blood vessel often becomes abnormally narrow (stenosis). CVCs also pose a higher risk for infection, and patients have to be careful with their daily hygiene or if their leisure activities include swimming or bathing. Sometimes, a CVC makes it hard to obtain high blood flows, which may affect the efficacy of toxin removal.

How is CVC care performed

CVC care is usually done by nurses. The catheter exit site should be cleaned during each dialysis treatment. Personal protective equipment must be worn by the nurse. The patient should wear a mask while the dressing is changed and at any time the catheter is opened, such as during the connection and disconnection procedures. The sutures for non-tunnelled catheters must remain in place for as long as the catheter is inserted. If you have a tunnelled catheter, the sutures should be removed once the catheter cuff has healed into place.

Vascular access

Before you start haemodialysis you need a vascular access. This is the site on your body where blood is removed and returned during dialysis

Hygiene

Recommendation of prevention measures in daily practice

Living with dialysis