Vascular Access for Kidney Dialysis

In a healthy person, the kidneys filter the blood to remove waste and excess fluid. The kidneys also produce hormones that control blood pressure, and they maintain special minerals (electrolytes) in your blood.

Chronic kidney disease (CKD) causes gradual kidney damage over months or years, progressively getting worse. The last stage of CKD is called end-stage kidney, or renal, disease, in which the kidneys fail. People with kidney failure require treatment with dialysis to filter the blood while waiting for a kidney transplant.

At the Vascular Access Clinic, our vascular surgeons offer the latest open and minimally invasive options for people who need vascular accesses for dialysis. We can help people who need access for the first time or have problems with existing access.

If you have CKD, your primary care doctor or nephrologist (kidney specialist) will monitor your health as your kidney function declines. When the kidneys lose about 85 to 90 percent of their function, your doctor refers you to our vascular surgeons.

Assessment for vascular access

We begin with a complete evaluation that includes a physical exam and imaging. The type of imaging depends on whether you’re getting your first vascular access or have an existing one:

• Getting access for the first time: We use traditional ultrasound (imaging from sound waves) to map your veins, typically in your nondominant arm. The images help your surgeon select the best blood vessels to work with for the creation of access.
• Getting care for an existing access: We use duplex ultrasound, which combines traditional ultrasound with Doppler ultrasound, capturing movement. This pairing helps us assess blood flow through your existing access. Another imaging study we may use, computed tomography (CT) angiogram, involves a contrast dye injected into the access. A CT scan picks up the contrast dye, showing any blood flow problems we need to correct.

Using the assessment, your vascular surgeon works closely with you to determine which type of access will best meet your needs. For people who are receiving access for the first time, our skilled surgeons have experience in a range of techniques, such as:

• Arteriovenous (AV) fistula: This long-term access point connects a vein to an artery, usually in your arm. The vein widens and thickens, becoming strong enough to handle large amounts of blood flowing quickly during dialysis. An AV fistula is the best type of access because it lasts longer, provides strong blood flow, and has a lower risk of infection or clots. But a fistula takes two to three months to mature and develop before dialysis can begin.
• AV graft: If your veins are too small for a fistula or the fistula does not fully develop, an AV graft is a good option. The surgeon connects an artery to a vein using a prosthetic tube. Although an AV graft is ready to use in two to three weeks, the risk of infections or clots rises.
• Venous catheter: For people who need to start dialysis before a fistula or graft is possible, a catheter (thin, flexible tube) provides short-term access. Your surgeon places the tube into a vein in your neck or upper thigh for use during dialysis. Later, we can remove the catheter and replace it with a better option — either an AV fistula or graft.
• Endovascular access: Henry Ford is expanding your options for receiving dialysis access with the addition of a minimally invasive technique. For endovascular dialysis access, our specialists perform a catheter-based procedure to create an AV fistula. Your surgeon inserts a thin tube through a small puncture in your upper thigh. Using instruments inserted through the catheter, your surgeon connects a vein to an artery to create access.

Some people with existing access experience problems that limit blood flow during dialysis. These problems can include blood clots and arm swelling. To salvage the access, our vascular surgeons offer several options:

• Minimally invasive procedures: For narrowed access, we may perform an endovascular (catheter-based) procedure to widen it. Your surgeon inserts a thin tube with a wire through a small puncture at your AV fistula or AV graft to reach the narrowed area. The surgeon then inflates a tiny balloon at the end of the catheter to widen the access. Some people also need a stent (miniature mesh tube) implanted in the access to hold it open.
• Thrombectomy (blood clot removal): Your surgeon performs a catheter procedure to break up and remove the clot from the vascular access.

Our vascular surgeons can also place catheters for people with autoimmune disorders, conditions that cause antibodies to mistakenly attack the body. The procedure, called plasmapheresis, separates the blood into two parts — the liquid (plasma) containing the antibodies, and the blood cells. The unhealthy plasma is then replaced with healthy plasma from a donor.