Dialysis is the most common treatment for patients who have acute or chronic kidney (renal) failure. When a kidney fails, dialysis — either hemodialysis or peritoneal dialysis — is a life-saving treatment. Dialysis uses a machine to send the patient’s blood through a filter, called a dialyzer, outside the body. Dialysis access surgery creates the vein which is used to remove and return blood to the body. It is a surgical procedure performed by Brigham and Women’s Hospital’s vascular surgeons.
Dialysis access surgery is usually done well before dialysis therapy can begin. This gives the access site time to mature and avoids the use of temporary catheters.
At the Heart & Vascular Center at Brigham and Women’s Hospital (BWH), our vascular surgeons are high-volume performers in all types of vascular procedures including dialysis access surgery. Our board certified surgeons’ experience and collaboration with a multidisciplinary team of specialists enable them to provide state-of-the-art services with compassion and care.
With 47,000 outpatient visits each year, the BWH Heart & Vascular Center is one of the largest in the United States, treating over 7,000 inpatients and performing more than 8,000 procedures annually at our state-of-the-art Shapiro Cardiovascular Center.
An arteriovenous fistula (AV fistula) or arteriovenous graft (AV graft) are two types of vascular accesses which are designed for long-term use. A third type of vascular access — the venous catheter — is usually used for short-term use.
The best way to establish long-term hemodialysis access is to construct an arteriovenous fistula (AV fistula).
An AV fistula is a connection, made by a vascular surgeon, of an artery to a vein. Arteries carry blood from the heart to the body, while veins carry blood from the body back to the heart. The surgeon usually places an AV fistula in the forearm or upper arm. An AV fistula causes extra pressure and extra blood to flow into the vein, making it grow large and strong. The larger vein provides easy, reliable access to blood vessels. Without this kind of access, regular hemodialysis sessions would not be possible. Untreated veins cannot withstand repeated needle insertions. They would collapse the way a straw collapses under strong suction.
A surgeon usually performs the procedure in the operating room. Discomfort is minimal and patients sometimes fall asleep during the one- to two-hour procedure. Patients are usually able to return home later that same day. The fistula usually requires from six to twelve weeks for the veins to dilate prior to initial dialysis use.
Not every patient is suitable for an AV fistula. Veins can be damaged over time due to repeat needle sticks for IV fluids, blood work and/or medicines. The resulting scar tissue can make creation of an AV fistula difficult or impossible.
When properly constructed, and with satisfactory maturation, an AV fistula can function for many years.
An arteriovenous graft (AV graft) is a looped, plastic tube that connects an artery to a vein. Arteries carry blood from the heart to the body, while veins carry blood from the body back to the heart. An AV graft is most often used when the patient does not have satisfactory veins for an AV fistula. In this procedure, surgeons connect an artery and a large vein in your wrist, elbow or armpit using a graft made of synthetic fabric. The graft works very well to provide dialysis access.
During an AV graft, a vascular surgeon sews the graft to an artery and tunnels it, just under the skin, creating a loop back to the starting incision where it is then sewn to a vein. The long loop gives the dialysis nurses space to access the graft. AV grafts can be safely used in a shorter time than AV fistulas, as no maturation of the vessels is necessary. Grafts have a lifespan of approximately two to three years but can often last longer. However, AV grafts can be more troublesome than AV fistulas. Blood is more likely to clot in grafts because they are made of foreign material. When this happens, interventional procedures can remove the clot and restore blood flow for dialysis.
An AV graft is more likely than an AV fistula to have problems with infection and clotting. Repeated blood clots can block the flow of blood through the graft. However, a well-cared-for graft can last several years.
For peritoneal dialysis, a catheter (a long tube) is advanced through a small incision in the abdomen deep into the lower part of the peritoneal cavity (the membrane lining the inside of the abdomen). The catheter is then tunneled under the skin for several inches, bringing the tube up through the skin at a different location.
Tunneling the catheter reduces the likelihood of infection in the peritoneal cavity.
The catheter is used to fill the abdomen with a cleansing liquid called dialysis solution. The walls of the abdominal cavity are lined with a membrane called the peritoneum, which allows waste products and extra fluid to pass from the blood into the dialysis solution. The solution contains a sugar called dextrose that will pull wastes and extra fluid into the abdominal cavity. These wastes and fluid then leave the body when the dialysis solution is drained. The used solution, containing wastes and extra fluid, is then thrown away.
Patients are usually able to return home the same day as the surgery. Peritoneal dialysis can begin when the incisions heal, usually about 2 to 4 weeks after the access surgery.
The Brigham and Women's Heart & Vascular Center is located in the Shapiro building, across the street from BWH’s main 75 Francis Street entrance. The Center brings together the full range of services in one location, fostering seamless and coordinated care for all cardiovascular patients.
If you are having surgery or a procedure, you will likely be scheduled for a visit to the Watkins Clinic in the Shapiro Center for preoperative information and tests.
The day of surgery, your care will be provided by surgeons, anesthesiologists and nurses who specialize in dialysis access surgery. After your procedure, you will recover in the post-surgical care unit where you will receive comprehensive care by an experienced surgical and nursing staff.
During your surgery, family and friends can wait in the Shapiro Family Center where staff members will provide surgery updates.
In addition to our vascular surgeons, patients also benefit from the teamwork of cardiovascular imaging experts and radiologists and anesthesiologists, all experts in vascular disorders. They work alongside nurses, physician assistants, physical therapists, dietitians and social workers to achieve outstanding outcomes for our patients.
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