In the context of this article, dialysis access is an entranceway into your bloodstream that lies completely beneath your skin and is easy to use. The access is usually in your arm, but sometimes in the leg, and allows blood to be removed and returned quickly, efficiently, and safely during dialysis or, less commonly, for other procedures requiring frequent access to your circulation.

For both fistulas and grafts, the connection between your artery and vein increases blood flow through the vein. In response, your vein stretches and becomes strengthened. This allows an even greater amount of blood to pass through the vein and allows your dialysis to proceed efficiently. In the weeks after surgery, the fistula begins to mature. The vein increases in size and may look like a cord under your skin. The whole process of maturation, which is a beneficial feature that permits the blood flow to increase in the fistula, typically takes 3 to 6 months. Some fistulas may take as long as a year or more to develop fully, but this is unusual. Once matured, a fistula should be large and strong enough for dialysis technicians and nurses to insert the large dialysis needles easily. If it fails to mature in a reasonable period of time, however, you may need another fistula.

A graft placed between an artery and vein can usually be used for dialysis within 2-6 weeks, when it is healed sufficiently. Usually fistulas are preferred to grafts, however, because fistulas are constructed using your own tissue, which is more durable and resistant to infection than are grafts. However, if your vein is blocked or too small to use, the graft provides a good alternative.

If you have chronic kidney failure and need long-term hemodialysis, you may require dialysis access. You may not be a good candidate for a fistula if your veins are too small or are scarred from frequent placement of intravenous catheters (thin, flexible tubes inserted into veins to deliver medicine) or needles to draw blood. In that event, you may be eligible for a graft access procedure. You also may not be a good candidate for a fistula if your arteries are severely blocked, although they might be repairable if necessary. Your vascular surgeon will probably be reluctant to use a graft if you have an ongoing infection since the graft itself might become infected. If this happens, the infected graft might need to be removed in order to clear up the infection.

Typically you will have the procedure on an outpatient basis. Most often, you will first be sedated and then your surgeon will numb the area where the fistula or graft will go. In some cases, your anesthesiologist may give you supplemental sedation or put you to sleep.

Depending upon the quality of your artery and vein, your surgeon will try to construct the fistula with one incision using the forearm of the arm that you do not use as frequently. For example, if you’re left handed, your physician will place the fistula in your right arm, if possible. To perform the surgery, your physician joins a large vein under the skin to an artery nearby. The physician divides your vein and sews it to an opening made in the side of the artery. As a result, the blood flows down the arteries into the hand, as usual, and also some of this faster moving blood flows into the veins that lead back to your heart. The blood that normally traveled in your divided vein goes back to the heart through other veins, and there is usually plenty of blood remaining in your artery to supply your hand.

If you cannot receive a fistula because the vein is too small or blocked, your physician may construct a graft using a tube of man-made, plastic material. Less commonly, your physician may also choose to use a piece of a vein from your leg or a section of artery from a cow as alternative graft materials. Your physician sews the graft to one of your veins and connects the other end to an artery. Your physician may place the graft material straight or form a loop under the skin either in your lower arm, upper arm, or less commonly in your leg.

After the operation, you should initially keep the access area raised above your heart to reduce swelling and pain. Your surgeon may recommend an over-the-counter painkiller to relieve pain, if necessary.

Following the suggestions below will help you keep your new access site working properly in the weeks after the surgery:

You may initially feel some coolness or numbness in the hand with the fistula. These sensations usually go away in a few weeks as your circulation compensates for the fistula. However, if these sensations are severe or don’t disappear, tell your physician as soon as possible, because the fistula may be causing too much blood to flow away from your hand, a condition physicians call a “steal.”

You should perform exercises to grow and strengthen your fistula, after the pain from the surgery decreases, to make dialysis faster and easier. Your physician may recommend squeezing a soft object using the hand on the arm in which the fistula was placed.

Grafts may mature more quickly than fistulas depending upon the size of the vein to which the graft is initially attached. They sometimes can be ready in 2 to 3 weeks, but many physicians recommend waiting about 4 to 6 weeks before using a graft. Grafts have disadvantages over fistulas. Grafts are more likely than fistulas to become infected. Also, grafts usually last about 1 to 2 years, which is less than fistulas, which can often last up to 3 to 7 years. If you care properly for your graft, however, you can help it last for many years.

Sometimes access portals can take weeks or even months until they are ready for dialysis use. Until the portal is ready, you may have to use a catheter for dialysis.

Complications with dialysis access include, in addition to “steal” discussed above, clotting, narrowing, aneurysm formation in the access itself, infection, and bleeding.

Protecting the dialysis access is crucial for you. The following tips will help you care for a fistula or a graft: