Dialysis Access FAQ for Referral Coordinators
When is it time for my patient’s fistula or graft to be cannulated?
GRAFT
For a primary graft (not a revision) time to cannulation is typically 2-4 weeks depending on the type of graft as well as how the patient is healing their incisions. They will be seen in the office at approximately 2 weeks postoperatively and the decision for cannulation will be made by provider at that time.
FISTULA
Fistulas take approximately 4-6 weeks to mature. Our team will see these patients in the office for initial 2 week postoperative appointment. Then, between 4 and 6 weeks an ultrasound will be performed to evaluate the fistula. We generally use the “rule of 6’s” to initiate cannulation of the fistula. This means that the fistula is at least 6 mm in diameter, less than 6 mm below the skin edge and a flow rate of 600 mL/min. If the fistula does not meet this criteria, further intervention could be recommended in the form of a fistulogram with balloon assisted maturation or ligation of tributary branches. We may allow cannulation in patient’s who do not meet this criteria in certain instances.
Remember to use the entirety of the fistula or graft for cannulation.
When can the Perm Cath be removed?
We typically recommend 2 weeks of hemodialysis without needing to use PermCath prior to removing.
When should I order a fistulogram?
Fistulograms should be ordered for clinical indicators. These can include things such as alarms well in the machine, poor flow rates, or high venous pressures, among others. A fistulogram can also be indicated based upon physical exam such as arm swelling, poor thrill or bruit. Some patients get routine fistulograms for known recurrent stenosis.
When should I order a declot?
A declot should only be ordered under the specific instance that there is no thrill or bruit within the access. Pulling clots does not mean that the access is clotted. Some accesses have thrills that are difficult to feel, so it is imperative that a clinical team member listen to the access with a stethoscope to evaluate for bruit.
My patient says their hand is hurting on the side of the access. What should I do?
It is not uncommon to have some initial postoperative pain within the hand. Concerns for steal syndrome include wounds on the fingers, numbness and tingling in the hand, pain in the hand (sometimes only on dialysis). If there is concern for steal syndrome, patient should be promptly seen within the office.
My patient’s access is swelling or has aneurysms/pseudoaneurysms. Do they need a revision?
Aneurysms and pseudoaneurysm can occur in both fistulas and grafts. In the absence of skin changes, a fistulogram is most appropriate for those patients. If there is loss of pigmentation or a wound, an office visit would be the best choice to discuss a possible revision. If an aneurysm or pseudoaneurysm develops, it is recommended to avoid cannulating these areas. In the absence of alternate cannulation locations, the base of the pseudoaneurysm can be used for cannulation. These are often preventable by remembering to use the entirety of the fistula or graft for cannulation.
What do I do if my patients are has been infiltrated and unable to cannulate?
If unable to cannulate with significant bruising or swelling, those patients will need a Perm Cath for arm rest.
When to call dialysis coordinator:
Urgent Issues such as Lack of thrill or bruit, infiltration, skin changes overlying pseudoaneurysm, steal syndrome with hand wounds on the access side.
When to fax/refer:
Non urgent items such as new patients, non-urgent fistulograms or office visits, steal syndrome without hand wounds.