Why is it important for a patient to have a fistula or graft for dialysis access? [Dr. Spinowitz]

Q: Why is it important for a patient to have a fistula or graft for dialysis access?

A: In the past, the research regarding dialysis access has looked at what is more beneficial for a patient – to have a fistula or a graft, or a hemodialysis tunneled catheter. Historically, the belief was that those patients with dialysis catheters do a lot worse. If you take all patients starting with dialysis and you divide them up into those patients with a fistula or a graft, or a catheter on the other side, patients with catheters may experience increased infections and increased central venous stenosis resulting in swelling and other difficulties.

The opinion throughout the years was that this was all related to the dialysis catheter itself. With a catheter, there is an increased risk of infection because it is a foreign object that is introduced into the internal jugular vein, with the tip of the catheter being at the entrance of the heart. The other side of the catheter exits through the skin and has an entrance that allows for bacteria from the skin or the outside world to enter into the central circulation.

Over time, it has been established that not everybody requires a fistula or graft, and there is a subset of patients that can benefit sufficiently from a catheter. For these patients, the potential negative outcomes are outweighed by the less invasive treatment.

Those patients that can benefit have been looked into with many other studies. The point is that there are some patients, for example, those with comorbidities or who have a decreased ejection fraction so their heart is not strong enough to support a fistula or a graft, who may benefit from a tunneled hemodialysis catheter. However, these patients are few and far between. For the most part, those patients starting dialysis should start with a fistula or a graft.

In the video above, I draw a simplified picture of the fistula in order to explain what is actually going on inside the arm. This will also allow me to explain the complications and how we treat them. If we start from the heart and blood flowing out of the heart down the arteries towards the arm and the hand, the surgeon will create a connection between the arterial tree and the venous tree. The blood comes down the artery, down the arm towards the hand, but also, because of this new connection, the blood flows through the vein. This part is the fistula. This is where the needle will be placed for dialysis.

The word fistula means connection. However, in the dialysis world, the fistula is the area where the needle will be cannulated into the vein. If the patient does not have a good vein that is suitable for this connection, the surgeon will use a graft which is made of expanded polytetrafluoroethylene (ePTFE). This is connected through the artery into a larger vein higher up in the arm. The area that will be cannulated for dialysis will be the graft area.

The idea behind a fistula or a graft is that the body protects the fistula or the graft from infection, and from other problems, by using the barrier of the skin for protection.

The catheter exposes the circulation to potential infection from bacteria either on the skin, or from the outside world. Therefore, between the quality of life and decreasing risk of infection, the fistula or graft is an overall better option than the hemodialysis tunneled catheter.

More videos from the interview with Dr. Spinowitz of the Queens Endovascular Center as he describes the details of Dialysis Access Management:

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