Haemodialysis fistula and graft
The dialysis patient's lifeline in the arm. Protect it: no BP, no bloods, no cannula in that arm. Bleeding can be fatal, and a lost thrill is an emergency.
Also called: AV fistula, arteriovenous fistula, AVF, AV graft, arteriovenous graft, AVG, dialysis fistula, fistula arm
What it is
An arteriovenous fistula (AVF) is a surgically created join between an artery and a vein, usually in the arm, which over weeks develops a thick, high-flow vein that can be needled for haemodialysis. An AV graft (AVG) does the same job using a synthetic tube between an artery and a vein when the patient's own veins are inadequate. It is the patient's access for life-sustaining dialysis, and it must be protected.
The ED concerns are bleeding (which can be catastrophic), thrombosis (loss of the access), infection (especially of a graft), steal (hand ischaemia) and aneurysm. This entry is for adults; fistulas and grafts in children are rare and managed by paediatric nephrology.
How to recognise it
- A thickened, often visibly pulsatile vein or a soft synthetic tube under the skin of the forearm or upper arm, usually with needling marks from dialysis.
- A palpable thrill (a continuous buzz) and an audible bruit over a working access - their presence means it is flowing; their loss is a red flag.
- A patient who is on haemodialysis (knows their unit and schedule), often with an arm they tell you not to touch.
What it gets confused with
A tunnelled dialysis catheter is a large-bore line in the chest used when there is no working fistula or graft; it is infection-prone and is the lifeline when present. A fistula/graft is in the arm. A patient may have had both over time - check which is currently in use.
What goes wrong
Bleeding from the access
Bleeding from a needling site after dialysis, from an eroded or ulcerated aneurysm, or spontaneously. A high-flow access can bleed very fast.
Red flag
This can be fatal. Aneurysms lead to an increased risk of rupture and life-threatening haemorrhage
. Apply firm, focal pressure over the bleeding point (not a circumferential occlusion), elevate, and hold. If bleeding is catastrophic and uncontrollable, a proximal tourniquet is a life-over-access measure - stop the exsanguination and get vascular/renal help immediately.
Thrombosis (clotted access)
A sudden loss of the thrill and bruit, with the access feeling hard or pulseless; the patient may notice it has 'stopped buzzing'.
Red flag
A clotted fistula or graft is a time-critical problem - the access may be salvageable by urgent thrombectomy or thrombolysis if the renal/vascular team is called early. Do not wait.
Access infection
Redness, warmth, discharge or tenderness over the access, with or without fever; infection of a synthetic graft is particularly dangerous.
Red flag
Bacteraemia in these patients is often access-related: the guideline notes it is commonly though not exclusively access-related, and rates vary markedly by access type, being highest in those dialysing by graft or catheter
. An infected graft can erode and haemorrhage - take blood cultures, start antibiotics per policy, and refer urgently.
Steal syndrome
A cold, painful, pale or numb hand distal to the access, worse during dialysis - blood is diverted ('stolen') through the access away from the hand.
Red flag
Significant steal (rest pain, sensory or motor loss, tissue loss) threatens the hand and needs urgent vascular referral.
The first ten minutes
- Bleeding: focal pressure, not a tourniquet first. Press firmly on the exact bleeding point and hold; elevate the arm. Reserve a proximal tourniquet for catastrophic, uncontrollable haemorrhage - preserving life over the access - and call for help while you hold pressure.
- Protect the access arm throughout: no blood pressure cuff, no venepuncture, no cannulation and no tight dressings on that arm.
- Check the thrill and bruit. Their loss suggests thrombosis - call the renal/vascular team urgently, because early intervention may save the access.
- For infection, take blood cultures, start antibiotics per local policy, and refer - an infected graft is urgent.
- For an ischaemic hand (steal), assess perfusion and sensation and refer to vascular surgery urgently if severe.
- Involve the renal unit early for any access problem - they know the patient's access history and the plan.
Do not
Who owns it
The renal unit (and vascular surgery / interventional radiology for the access itself) own it. Tell them the access type and arm, whether the thrill and bruit are present, the problem (bleeding, clotted, infected, ischaemic hand), and the patient's dialysis schedule.
Who to call
The team and the criteria are national. The phone number is local, and this tool does not know it. Find it once, now, and write it on the department's own card — that is the part no website can do for you.
- Say the device name first
- Open with laryngectomy, LVAD, shunt — the single word changes who comes and what they bring. Do not bury it in the history.
- Say what you have already established
- Whether the device is patent, whether it has been removed or disturbed, and what you have already tried. The specialist is deciding whether to walk or run.
- Ask who owns it out of hours
- Device ownership and the on-call route often differ from the implanting specialty, and it is frequently a regional centre rather than your own hospital.
- The patient's own team is a resource, not an afterthought
- Named nurse specialists, home-care companies and device helplines answer questions nobody else can, and the patient usually has the number.
When the device is not the problem
A patient with a device gets pneumonia, sepsis, pulmonary oedema and myocardial infarction at the same rate as everybody else. The device is the most visible thing about them and it attracts the whole assessment.
- The NTSP says it out loud
- The project's own manual warns that
patients with tracheostomies can become unwell with all the problems that other patients get too. It is easy to become fixated with the tracheostomy.
The same sentence applies to every device in this tool. - Clear the device, then leave it
- Establish that the device is doing its job — the stoma is patent, the line draws back, the pump is running — and then assess the patient as you would anyone else.
- The anchoring runs both ways
- The opposite error is treating a device complication as a medical illness: a blocked gastrostomy read as vomiting, a baclofen pump failure read as sepsis.
- NTSP manual — Red flags · read in full
What the patient will be carrying
Dialysis patients know their unit, schedule and usually their access type, and are often emphatic about protecting the access arm. Many carry a kidney-care card with the renal unit's contact.
Scope of this page
This page covers recognising a fistula or graft and the ED response to its emergencies: control bleeding, protect the arm, detect thrombosis, treat infection and steal, and refer early. It does not teach access creation, cannulation for dialysis, thrombectomy or surgical repair, which belong to the renal and vascular teams. The UKKA guideline supports the access-protection, bacteraemia and aneurysm-rupture points; the immediate first-aid (focal pressure, a proximal tourniquet only as a last resort) and the steal-syndrome steps are standard ED and vascular practice rather than specific guideline recommendations. Written with adults in mind - fistulas and grafts are uncommon in children, and paediatric access is managed by paediatric nephrology.