Complications of arteriovenous access for haemodialysis

What it is

An arteriovenous fistula made for dialysis has its own list of complications, and each one has a typical timing that does most of the work in telling them apart.

• Early thrombosis: within 1 month. The fistula never matures and the thrill and pulse are absent. Evaluate for technical issues, and consider thrombectomy or revision.
• Failure to mature: 1-3 months. Small veins, low flow, difficulty cannulating. Percutaneous angioplasty or surgical revision.
• Steal syndrome: weeks to months, and common after 6 months.
• Aneurysm formation: months to years. Localized swelling of the fistula, which may bleed. Surgical repair if large or symptomatic.
• High-output cardiac failure: months to years. Dyspnea, edema, cardiomegaly and increased cardiac output. Consider flow reduction or ligation.
• Infection: early or late. Redness, warmth, pain and discharge. Antibiotics, and it may need surgical debridement.
• Pseudoaneurysm: weeks to months. A pulsatile mass which may rupture. Surgical repair or thrombin injection.

How it presents

Vascular access steal syndrome is blood being stolen from the distal limb through the fistula, causing ischemia during dialysis.

The key features are a hand that is pale, cold, painful and numb, worsening during dialysis, with distal pulses weak or absent. A hand that goes white, is paler than the other and slightly cool to touch, with no radial pulse felt on the ipsilateral forearm, is the classic presentation, and it appears typically some months after the creation of a brachio-cephalic arteriovenous fistula.