Vascular Access for 

Hemodialysis
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I

f you are starting hemodialysis treatments 

in the next several months, you need to 

work with your health care team to learn 

how the treatments work and how to get the 

most from them. One important step before 

starting regular hemodialysis sessions is preparing a vascular access, which is the site 

on your body where blood is removed and 

returned during dialysis. To maximize the 

amount of blood cleansed during hemodialysis treatments, the vascular access should 

allow continuous high volumes of blood 

flow. 

A vascular access should be prepared weeks 

or months before you start dialysis. The 

early preparation of the vascular access will 

allow easier and more efficient removal 

and replacement of your blood with fewer 

complications. 

The three basic kinds of vascular access for 

hemodialysis are an arteriovenous (AV) fistula, an AV graft, and a venous catheter. A 

fistula is an opening or connection between 

any two parts of the body that are usually 

separate—for example, a hole in the tissue 

that normally separates the bladder from 

the bowel. While most kinds of fistula are 

a problem, an AV fistula is useful because it 

causes the vein to grow larger and stronger 

for easy access to the blood system. The 

AV fistula is considered the best long-term 

vascular access for hemodialysis because it 

provides adequate blood flow, lasts a long 

time, and has a lower complication rate than 

other types of access. If an AV fistula cannot 

be created, an AV graft or venous catheter 

may be needed. 

What is an arteriovenous fistula? 

An AV fistula requires advance planning 

because a fistula takes a while after surgery to 

develop—in rare cases, as long as 24 months. 

But a properly formed fistula is less likely 

than other kinds of vascular access to form 

clots or become infected. Also, properly 

formed fistulas tend to last many years— 

longer than any other kind of vascular access. 

A surgeon creates an AV fistula by connecting an artery directly to a vein, frequently 

in the forearm. Connecting the artery to 

the vein causes more blood to flow into the 

vein. As a result, the vein grows larger and 

stronger, making repeated needle insertions 

for hemodialysis treatments easier. For the 

surgery, you’ll be given a local anesthetic. In 

most cases, the procedure can be performed 

on an outpatient basis. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From 

dialysis 

machine 

To 

dialysis 

machine 

Forearm arteriovenous fistula 

U.S. Department of Health
�

and Human Services
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NATIONAL INSTITUTES OF HEALTH 

National Kidney and Urologic Diseases 

Information Clearinghouse
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What is an arteriovenous graft? 

If you have small veins that won’t develop properly 

into a fistula, you can get a vascular access that connects an artery to a vein using a synthetic tube, or 

graft, implanted under the skin in your arm. The graft 

becomes an artificial vein that can be used repeatedly 

for needle placement and blood access during hemodialysis. A graft doesn’t need to develop as a fistula 

does, so it can be used sooner after placement, often 

within 2 or 3 weeks. 

Compared with properly formed fistulas, grafts tend 

to have more problems with clotting and infection and 

need replacement sooner. However, a well-cared-for 

graft can last several years. 

Looped graft 

Artery 

Vein 

One kind of AV graft 

What is a venous catheter for 

temporary access? 

If your kidney disease has progressed quickly, you 

may not have time to get a permanent vascular access 

before you start hemodialysis treatments. You may 

need to use a venous catheter as a temporary access. 

A catheter is a tube inserted into a vein in your neck, 

chest, or leg near the groin. It has two chambers to 

allow a two-way flow of blood. Once a catheter is 

placed, needle insertion is not necessary. 

Catheters are not ideal for permanent access. They 

can clog, become infected, and cause narrowing of the 

veins in which they are placed. But if you need to start 

hemodialysis immediately, a catheter will work for 

several weeks or months while your permanent access 

develops. 

For some people, fistula or graft surgery is unsuccessful, and they need to use a long-term catheter access. 

Catheters that will be needed for more than about 

Venous catheter for temporary hemodialysis access 

3 weeks are designed to be tunneled under the skin to 

increase comfort and reduce complications. Even tunneled catheters, however, are prone to infection. 

What can I expect during hemodialysis? 

Every hemodialysis session using an AV fistula or AV 

graft requires needle insertion. Most dialysis centers 

use two needles—one to carry blood to the dialyzer 

and one to return the cleansed blood to your body. 

Some specialized needles are designed with two openings for two-way flow of blood, but these needles are 

less efficient. For some people, using this needle may 

mean longer treatments. 

Some people prefer to insert their own needles, which 

requires training to learn how to prevent infection 

and protect the vascular access. You can also learn a 

“ladder” strategy for needle placement in which you 

“climb” up the entire length of the fistula, session by 

session, so you won’t weaken an area with a grouping 

of needle sticks. 

An alternative approach is the “buttonhole” strategy 

in which you use a limited number of sites but insert 

the needle precisely into the same hole made by the 

previous needle stick. Whether you insert your own 

needles or not, you should know about these techniques so you can understand and ask questions about 

your treatments. 

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What are some possible complications 

of my vascular access? 

All three types of vascular access—AV fistula, AV 

graft, and venous catheter—can have complications 

that require further treatment or surgery. The most 

common complications are access infection and low 

blood flow due to blood clotting in the access. 

Venous catheters are most likely to develop infection 

and clotting problems that may require medication and 

catheter removal or replacement. 

AV grafts can also develop low blood flow, an indication of clotting or narrowing of the access. In this 

situation, the AV graft may require angioplasty, a procedure to widen the small segment that is narrowed. 

Another option is to perform surgery on the AV graft 

and replace the narrow segment. 

Infection and low blood flow are much less common 

in properly formed AV fistulas than in AV grafts and 

venous catheters. Still, having an AV fistula is not a 

guarantee against complications. 

How should I take care of my vascular 

access? 

You can take several steps to protect your access: 

n	 Make sure your nurse or technician checks your 

access before each treatment. 

n	 Keep your access clean at all times. 

n	 Use your access site only for dialysis. 

n	 Be careful not to bump or cut your access. 

n	 Don’t let anyone put a blood pressure cuff on your 

access arm. 

n	 Don’t wear jewelry or tight clothes over your access 

site. 

n	 Don’t sleep with your access arm under your head 

or body. 

n	 Don’t lift heavy objects or put pressure on your 

access arm. 

n	 Check the pulse in your access every day. 

Hope through Research 

The National Institute of Diabetes and Digestive and 

Kidney Diseases (NIDDK) has many research programs 

aimed at improving the treatment of end-stage renal 

disease. The NIDDK established the Dialysis Access 

Consortium, which consists of seven clinical centers 

and a data coordinating center, to undertake interventional clinical trials to improve outcomes in patients 

with fistulas and grafts. 

Two randomized placebo-controlled clinical trials 

were designed and are nearly completed. The first 

trial evaluated the effects of the antiplatelet agent 

clopidogrel (Plavix) on prevention of early fistula 

failure. A second clinical trial is studying a drug that 

combines dipyridamole with aspirin (Aggrenox), with 

the goal of preventing access stenosis in hemodialysis 

patients with grafts. 

Participants in clinical trials can play a more active 

role in their own health care, gain access to new 

research treatments before they are widely available, 

and help others by contributing to medical research. 

For information about current studies, visit 

www.ClinicalTrials.gov. 

For More Information 

Your health care team will help you learn more about 

how to care for your access site. For a copy of the 

booklet Getting the Most From Your Treatment: 

What You Need to Know About Hemodialysis Access, 

contact 

National Kidney Foundation 

30 East 33rd Street 

New York, NY 10016 

Phone: 1–800–622–9010 

or 212–889–2210 

Internet: www.kidney.org 

For a copy of the booklet Understanding Your Hemodialysis Access Options, contact 

American Association of Kidney Patients 

3505 East Frontage Road, Suite 315 

Tampa, FL 33607 

Phone: 1–800–749–2257 

Email: info@aakp.org 

Internet: www.aakp.org 

Life Options has developed an interactive patient 

education website called Kidney School. Module 8 of 

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this program addresses vascular access for 

hemodialysis. To view this module, go to 

www.kidneyschool.org or contact 

Life Options 

c/o Medical Education Institute, Inc. 

414 D’Onofrio Drive, Suite 200 

Madison, WI 53719 

Phone: 1–800–468–7777 

Email: lifeoptions@MEIresearch.org 

Internet: www.lifeoptions.org 

www.kidneyschool.org 

The Centers for Medicare & Medicaid 

Services, the End-Stage Renal Disease 

Networks, and the Institute for Healthcare 

Improvement (IHI) launched the National 

Vascular Access Improvement Initiative 

in 2003. Materials from the Fistula First 

Change Package are available through the 

IHI website or by contacting 

Institute for Healthcare Improvement 

20 University Road, 7th Floor 

Cambridge, MA 02138 

Phone: 1–866–787–0831 

or 617–301–4800 

Internet: www.ihi.org 

www.fistulafirst.org 

Acknowledgments 

Publications produced by the Clearinghouse 

are carefully reviewed by both NIDDK scientists and outside experts. 

About the Kidney Failure Series 

The NIDDK Kidney Failure Series includes 

booklets and fact sheets that can help the 

reader learn more about treatment methods 

for kidney failure, complications of dialysis, 

financial help for the treatment of kidney 

failure, and eating right on hemodialysis. 

Free single printed copies of this series can 

be obtained by contacting the National 

Kidney and Urologic Diseases Information 

Clearinghouse. 

National Kidney and Urologic 

Diseases Information Clearinghouse 

3 Information Way 

Bethesda, MD 20892–3580 

Phone: 1–800–891–5390 

TTY: 1–866–569–1162 

Fax: 703–738–4929 

Email: nkudic@info.niddk.nih.gov 

Internet: www.kidney.niddk.nih.gov 

The National Kidney and Urologic Diseases 

Information Clearinghouse (NKUDIC) is a 

service of the National Institute of Diabetes 

and Digestive and Kidney Diseases (NIDDK). 

The NIDDK is part of the National Institutes 

of Health of the U.S. Department of Health 

and Human Services. Established in 1987, 

the Clearinghouse provides information 

about diseases of the kidneys and urologic 

system to people with kidney and urologic 

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This publication is not copyrighted. The Clearinghouse encourages users of this publication to duplicate 

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This publication is available at 

www.kidney.niddk.nih.gov. 

You may also find additional information about this 

topic by visiting MedlinePlus at www.medlineplus.gov. 

This publication may contain information about 

medications. When prepared, this publication 

included the most current information available. 

For updates or for questions about any medications, 

contact the U.S. Food and Drug Administration 

toll-free at 1–888–INFO–FDA (1–888–463–6332) 

or visit www.fda.gov. Consult your doctor for more 

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The U.S. Government does not endorse or favor any 

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If a product is not mentioned, the omission does not 

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U.S. DEPARTMENT OF HEALTH 

AND HUMAN SERVICES 

National Institutes of Health 

NIH Publication No. 08–4554 

February 2008 

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