Taichung Armed Forces General Hospital

I. Generally, there are three types of permanent vascular access:
Native arteriovenous (AV) fistulas, artificial grafts, and cuffed double-lumen venous catheters, as described below:

(1) Native Arteriovenous Fistula:
Created by surgically connecting a patient’s own artery and vein. It requires 2 to 6 months to mature (i.e., the venous segment expands and thickens, becoming suitable for repeated dialysis needle access).

The first-choice site is the radial artery to cephalic vein connection in the non-dominant hand (e.g., left hand for a right-handed person), forming a large superficial vein ideal for puncture.

• Advantages: Long-term use (3-year patency rate 65–75%, with some reports of usage up to 20 years) and lower rates of late thrombosis and infection.
• Disadvantages: Higher risk of early thrombosis compared to artificial grafts; 24–27% of fistulas fail to mature adequately for dialysis use, especially in patients with diabetes or arteriosclerosis. Factors like age, obesity, small or deep veins, and excessive vein branches can affect success. Previous vein punctures can also cause vessel sclerosis and occlusion—hence, avoid unnecessary IV injections in potential access limbs.
  The second option is the brachial artery to cephalic vein connection, located above the elbow, with the vein running along the front of the biceps, making puncture relatively convenient.

The third is the brachial artery to basilic vein connection, but the deeper location makes puncture more difficult.

(2) Artificial Graft:
When native vessels are unsuitable, an artificial graft (primarily made of PTFE) can be used as a bridge between an artery and vein.

• Advantages: Matures within 2–3 weeks (ideally after swelling subsides), less prone to early thrombosis, and tolerates multiple thrombectomy procedures.
• Disadvantages: Lower 3-year patency rate (30–50%) and higher infection and thrombosis rates.

(3) Cuffed Double-Lumen Venous Catheter:
Typically placed in the internal jugular vein, featuring a Dacron cuff and a tunneled design to reduce infection risk. This allows use for several months, with some reports suggesting 2-year patency comparable to artificial grafts.
Note: Catheter-related infections, bacteremia, and central vein stenosis are major complications. Therefore, this option is usually reserved for temporary use while waiting for fistula maturation and is not recommended as permanent vascular access unless no other options are available.

II. Vascular Access Care:
Postoperative elevation of the limb reduces swelling. Begin prescribed hand and arm exercises (e.g., squeezing a ball) 2–7 days after AV fistula surgery as directed by healthcare providers. Avoid blood draws, IV treatments, or blood pressure measurements on the access limb, and prevent any compression on the access site.
Daily checks for thrill and bruit are important. Ideally, an AV fistula should mature for about 3 months before first use to maximize longevity; if not, it should at least mature for one month.
Artificial grafts should not be used within 2 weeks unless ultrasound guidance is available. Premature use can cause bleeding, hematomas, graft tearing, or loss of access.