What is an "access: and why do I need one?
You are either currently on dialysis or your kidney doctor (nephrologists) believes you will need to be on dialysis very soon. Dialysis is a way of cleansing your blood by removing many of the waste products that your body makes. In order to do this, a large amount of blood needs to be taken out of your body very quickly, cleaned in the dialysis machine and then returned to your bloodstream. The better and faster that this can be done, the better the dialysis will work and the better you will feel. This is a very specialized task and it requires some specialized methods of getting your blood into the machine and back to you. There are three basic ways to do this include catheters, fistulas and grafts. All or any of these methods are called a dialysis "access."
Types of Dialysis Access
Catheters are long plastic tubes that are inserted into the large veins in your neck or chest and then sit close to your heart. They are also known as "Tesios" or "Vascaths" or "Schonns." They have some advantages including that they can be used right away and the operative procedures to insert them is relatively straightforward, but there are many disadvantages that make them a poor choice for long term use. Infections are common afterwards. Our bodies just don't respond well to plastic and eventually the body "walls off" the catheter and they stop allowing good dialysis. You may need a catheter for a short time while another type of access is readied, although it's best to avoid a catheter altogether, if possible as they can cause long term damage to your veins.
The best option for dialysis access is known as a "fistula." Other names for fistulas that you may hear include "Ciminos", or "turn downs" or "basilic transpositions" or "native vein fistulas." These are formed by connecting an artery in your arm (the blood vessel that brings blood from your heart to your hand) directly to a vein (the blood vessel that brings blood from your arms back to your heart.) Over time the vein gets bigger and tougher until it can be used for dialysis. This process of getting bigger and tougher is called becoming "mature." Once a fistula is "mature" it is the best type of access for dialysis. It allows excellent blood flow to and from the machine so you get better dialysis and feel better. They are usually trouble-free at this point, rarely get infected, and last for years. In addition, the operation used to make a fistula is oftentimes simple and results in very little discomfort and a very small scar. Unfortunately, not everyone has veins that are easily made into fistulas. Another drawback is that even if your veins are good enough to be used for a fistula it can often take months or another procedure for a fistula to "mature."
If your veins are not good enough to be made into a fistula, you may need a "graft." This is a plastic tube inserted under your skin in your arm. One end is connected to an artery, the other end to a vein and dialysis needles are placed through the skin and into this graft. Because they are plastic, grafts are more likely to get infected than fistulas, but the biggest problem with grafts is that they often clot off and then have to be reopened with another procedure, whether in surgery or by radiologists. The operation to put in a graft usually results in much more swelling and tenderness than with a fistula as well. Still, although they are not as good as fistulas, they provide much better dialysis than catheters.
How do I decide which dialysis access is right for me?
At your surgical preoperative visit, your surgeon will evaluate what type of dialysis access will be right for you. Often an ultrasound will be done to look at the veins in your arms to see if they are adequate for a fistula. You will get a chance to have any questions answered and will receive an appointment for the operating room. Most of the time, surgery for dialysis access is done as an outpatient and you go home the same day. Occasionally, it may be necessary for you to stay in the hospital overnight. It is rarely necessary for you to go under general anesthesia. Most patients find that light sedation and local anesthesia is very comfortable and allows you to avoid any possible anesthesia complications.
Getting ready for your vascular access
- Do NOT eat or drink anything after midnight
- Check in for your surgery at the assigned time
- If you are on Coumadin or Insulin, check with your surgeon for specific instructions
- Bring a list of medications you take including the dosage and the last time you took the medication
- Leave all valuable and medications at home
- You will not be allowed to drive yourself home so please arrange for a ride!
What happens after my dialysis access is placed?
After your dialysis access has been placed, you will receive an appointment to see your surgeons in approximately two weeks. If you received a fistula, the nurses at the dialysis units will give you some exercises to help develop your veins after the wounds have healed. We recommend squeezing a rubber ball 10 times twice daily.
Post operative care following dialysis access
- Keep your arm elevated on a pillow above the level of your heart until the swelling is gone.
- Palpate your arm daily for a thrill or pulse.
- Do not use any dressings that wrap around your arm or dialysis access site.
- Avoid tight jewelry or clothes on your access arm.
- Do not allow any blood draws or blood pressures in your access arm.
- Take your pain medicine as directed. You may change to Tylenol at any time.
- Call your surgeon for any unusual pain, redness, drainage or bleeding. A small amount of staining on your dressing is normal.
- Call your surgeon if your hand on your access arm feels unusually cold, numb or painful.
- You may remove the dressing and replace with bandaids 2 days after your surgery.
- You may shower 2 days after your access was placed but do NOT soak in a tub or hot tub for 2 weeks.
- Please call your doctor with any concerns or questions!