Fistula / Graft care

Understanding Fistulas and Grafts

Why do I need a fistula/graft?

To carry out haemodialysis, a good, strong blood supply is required to circulate blood from your body through the dialysis machine and back.

What is an arteriovenous fistula?

• A fistula is a direct connection created surgically between an artery and a vein.
• Blood from the artery flows directly into the vein, causing the vein to mature over six to eight weeks, becoming bigger and firmer.
• The enlarged, firm vein allows two needles to be inserted safely during treatment: one needle takes blood out of the body to the dialysis machine, and the second returns clean blood back to the body.
• Main Advantages: Lower risk of infection compared to a Central Venous Catheter (CVC) and higher overall quality of dialysis.

What is a graft?

A graft is similar to a fistula, but a synthetic tube (artificial vein) is used to connect the artery and vein when natural blood vessels cannot be joined directly. Dialysis needles will be inserted into this artificial vein. Grafts are typically ready for use sooner than natural fistulas.

Medical Process and Surgical Operation

What happens next?

Following initial education by the Pre-Dialysis Team in clinic, the Renal Vascular Access Team will refer you to a vascular surgeon or to the Ultrasound Department for an arm scan to determine the optimal site for the fistula.

Your second appointment will take place at the Pre Assessment Clinic, it could be by telephone and a face to face appointment at Leeds General Infirmary, where paperwork, pre-op blood tests, MRSA swabs, and prescribed decolonisation treatments will be completed.

The surgical operation

Location & schedule

• Usually performed as a Day Case procedure at David Beevers Day Unit (St. James’s University Hospital), Wards L26/L15 (Leeds General Infirmary), or Huddersfield Royal Infirmary.
• Patients are normally asked to arrive on the ward at 07:15 AM. Overnight stay may be required if you live alone or have complex medical needs.

Procedure details

Performed under local anaesthetic or a regional arm block (which numbs the entire arm).
The surgery takes between 45 and 90 minutes depending on the type of fistula/graft.

Post-Operative Care and Exercises

After discharge care

• Check Thrill & Bruit every four hours by placing your first two fingers gently over or just above the wound site.

• Thrill: The physical sensation of blood rushing through the fistula (a continuous buzzing or vibrating feeling).
• Bruit: The sound of blood traveling through the fistula (a continuous ‘whooshing’ sound heard with a stethoscope).
• Arm Elevation: Keep your arm elevated on at least two pillows until swelling subsides.
• Wound Care: Keep the surgical dressing clean and dry for 3–5 days if you have a smaller incision, or 5–7 days for a longer incision. After this time, the dressing can be removed and you may shower, provided the wound is healing well. Gently pat the wound dry.
• Lifting Restrictions: Avoid heavy lifting for the first two weeks to allow healing.
• Hand and Arm Warmth: Keep your arm and hand warm to encourage healthy blood circulation.
• Fistula Follow-Up: If you are a pre-dialysis patient, the Renal Vascular Access Team will contact you by telephone during the first and second weeks after surgery to check on your recovery and fistula. Further follow-up will then be arranged until you start on dialysis.
• If you are already receiving dialysis, your dialysis unit will check your newly created fistula during your dialysis sessions and monitor its development and function.
• Consider wearing a fistula alert band. This helps others quickly identify that you have a fistula in place and reminds others: “NO BLOOD PRESSURE • NO NEEDLES • NO BLOOD TESTS” on that arm.

Fistula exercises

Once stitches are removed (if present) and the wound is fully healed (approx. two weeks post-surgery), you can start fistula exercises to strengthen and dilate the blood vessels, aiding maturation:

Equipment: Use a soft stress ball or a rolled-up soft cloth/sock.

Position: Allow your fistula arm to hang down loosely by your side to encourage blood flow down the limb.

Technique: Gently squeeze the soft ball in the hand of your fistula arm. Hold the squeeze for 3–5 seconds, then release.

Duration & frequency: Perform the squeezing motion for no more than two minutes per session. Repeat three to four times a day.

When can my fistula be used?

It usually takes between six to eight weeks for a fistula to mature and become strong enough for regular dialysis. If complications like stenosis (narrowing) occur, maturation may take longer.

If you currently have a Central Venous Catheter (CVC), staff will arrange for its removal once your fistula/graft is cannulated routinely.

Daily Maintenance and Crucial Precautions

Daily fistula checks and mandatory ‘DO NOT’ Rules

Daily checks:

• Feel daily for the thrill/buzz (must be present).

• Inspect skin for signs of infection (redness, discharge/pus, warmth, swelling/puffy arm, changes in skin colour: red/grey/blue).
• Check for nerve issues: numbness, tingling, or unusual coldness in the hand/arm.

Maintaining skin health

Frequent use of antiseptic skin cleansers and medical tapes during dialysis can disrupt the normal barrier function of the skin, causing it to become dry, itchy, red, sore, or flaky. This increases infection risks.

We recommend applying a plain, non-perfumed moisturiser to the skin on your fistula arm daily (avoiding open needle sites).

Recognising and Managing Complications

Bruising or Swelling

Common in new fistulas/grafts when needle punctures leak small amounts of blood into tissue. Report all bruising to dialysis staff.

Redness, Heat, or Infection

Redness, heat, pain, or swelling are key signs of infection. Report immediately to dialysis staff. Skin reactions may also stem from tape/cream allergies.

Aneurysm Development

Swollen enlarged areas caused by repeated needle insertion in the exact same spot. Staff use ‘rope ladder’ or ‘buttonhole’ site rotations. Tell staff immediately if skin looks thin, shiny, pulses visibly, or swells sudden

Steal Syndrome

Occurs when the fistula/graft diverts (‘steals’) too much oxygenated blood away from the hand. Symptoms include coldness, pain, or tingling in fingers. (If wearing gloves, staff will ask to remove them to inspect).

Clotted Fistula / Reduced Flow

Loss or weakening of the physical buzz/thrill, or inability to reach target blood flow on dialysis. Inform staff IMMEDIATELY as intervention is urgent.

Scab

If a scab over your needle site does not heal quickly or gets larger, let the dialysis staff know as this can lead to a risk of bleeding. Do NOT Pick or Scratch.

Bleeding during dialysis

If blood starts to ooze around your needles during dialysis or it takes longer to stop bleeding at the end of treatment tell the dialysis staff immediately.

Emergency Protocol: Excessive Bleeding at Home

Critical Medical Emergency Instructions

While profuse bleeding between dialysis sessions is rare, it is a life-threatening emergency. If heavy bleeding occurs at home, follow these steps immediately:

1. Apply Firm Direct Pressure: Press firmly directly on the bleeding point using TWO fingers and a clean gauze.
   
   Do NOT use thick towels or bulky dressings, as they prevent focused, effective pressure.
2. Alert Others Immediately: Get help from anyone nearby. Rapid blood loss can cause light headedness or fainting.
3. Lie Down & Elevate: Lie flat immediately. Elevate the bleeding limb high above your heart, having someone assist you to hold it up while maintaining firm pressure.
4. Call 999 immediately: For profuse bleeding, call 999 right away and state clearly: ‘EXCESSIVE BLEEDING FROM VASCULAR FISTULA’. If it is a slower bleed that does not stop with pressure, call 999 after 30 minutes.
5. Remain Calm: Heavy bleeding can be controlled with firm, direct pressure in the exact right spot.
6. Hospital Follow-Up: Always inform your dialysis unit about any bleeding episodes. You must be evaluated by a vascular surgeon.

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