Dialysis Access — Catheter Placement and AV Access Intervention

Dialysis Access Hierarchy

Indications

Tunneled HD Catheter Placement

• ESRD requiring hemodialysis without a functional AVF or AVG
• Bridge while AVF or AVG matures (minimum 6+ weeks for AVF; days for AVG)
• Patients not candidates for AVF or AVG — poor vessel anatomy, limited life expectancy, or patient refusal of surgical access
• Site preference: right IJV (preferred) → left IJV → femoral vein (highest infection risk; last resort)
• Avoid subclavian vein — central vein stenosis risk compromises future ipsilateral AVF/AVG

Fistulogram and Angioplasty

• AVF or AVG dysfunction: elevated venous pressure during dialysis, inadequate flow rates, prolonged bleeding post-dialysis, change in bruit or thrill character
• Failure of AVF to mature (FTM): common — especially upper arm veins; fistulogram identifies stenosis at the anastomosis or juxta-anastomotic segment that prevents adequate dilation
• Recurrent access thrombosis: requires declotting followed by angioplasty of the underlying culprit stenosis

AV Access Declotting (Thrombolysis/Thrombectomy)

• Thrombosed AVG: pharmacomechanical thrombolysis (PMT) ± angioplasty of culprit stenosis — primary endovascular treatment; restores primary patency in ~80% of cases
• Thrombosed AVF: more challenging; PMT ± surgical thrombectomy; lower success rate than AVG declotting; often requires surgical revision for definitive management

Contraindications

• Ipsilateral subclavian or brachiocephalic stenosis/occlusion (central vein stenosis) — work up with upper extremity duplex before access planning; central vein stenosis makes ipsilateral AVF/AVG futile and causes venous hypertension; history of prior ipsilateral subclavian catheter is the major risk factor
• Bacteremia or active systemic infection — do not place a tunneled catheter until source is controlled; treat systemic infection first; tunneling through infected tissue is contraindicated
• ESRD with planned peritoneal dialysis — HD catheter not appropriate; coordinate access plan with nephrology before any intervention
• Uncorrectable coagulopathy — correct INR and platelets before elective access procedures; urgent interventions (e.g., sepsis source control) may require accepting higher bleeding risk

Relevant Anatomy

Hemodialysis Catheter Anatomy

The preferred venous route for a tunneled HD catheter is the right IJV → brachiocephalic vein → SVC → right atrium. This provides a direct, relatively straight path with minimal angulation. The left IJV is longer with a sharper angle at the brachiocephalic-SVC junction and is associated with higher rates of catheter malposition and central vein injury.

Tip position: the RA-SVC junction or within the right atrium (1–2 cm into RA) — significantly deeper than a standard CVL tip, which is positioned at the cavoatrial junction or distal SVC. The deeper position is necessary to achieve the high flow rates (300–500 mL/min) required for adequate hemodialysis; atrial tip placement is acceptable and expected for HD catheters. Confirm tip position fluoroscopically before the first use.

Cuff position: the dacron cuff should lie subcutaneously, 1–2 cm from the skin exit site — this promotes fibrous ingrowth that anchors the catheter and forms a barrier against tracking infection. Subclavian HD catheter placement should be avoided due to the high risk of central vein stenosis, which permanently impairs any future ipsilateral arm AVF or AVG.

AV Access Anatomy

Understanding the configuration of each access type is essential for fistulogram interpretation and intervention planning:

• Radiocephalic AVF (Brescia-Cimino): radial artery to cephalic vein at the wrist; primary fistula of choice; lower flow than brachial-based AVF; common stenosis at juxta-anastomotic segment
• Brachiocephalic AVF: brachial artery to cephalic vein at the antecubital fossa; high flow; risk of steal syndrome (hand ischemia) due to high-volume diversion; cephalic arch stenosis common
• Brachiobasilic AVF: requires transposition surgery (basilic vein runs too deep for cannulation in its native position); highest flows; highest steal risk
• AVG (synthetic PTFE): typically loop configuration in forearm or straight/loop in upper arm; graft-to-vein anastomosis is the most common site of stenosis and thrombosis

Common stenosis locations: juxta-anastomotic segment (most common for AVF failure to mature), mid-graft body (pseudointimal hyperplasia), graft-vein anastomosis (most common cause of AVG thrombosis), cephalic arch (brachiocephalic AVF), and central vein (subclavian or brachiocephalic — particularly after prior central catheter).

Pre-Procedure Checklist

For Catheter Placement

• Right IJV ultrasound — confirm patency and compressibility before proceeding
• If central vein patency is in question (prior central catheter, arm swelling) — CT venogram or contrast venogram before catheter placement
• Coagulation status: CBC (platelets), INR; target platelets >50,000 and INR <1.5 for elective placement
• Antibiotic prophylaxis per institution protocol — often cefazolin 1–2g IV for tunneled HD catheter; administer before procedure
• NPO minimum 4–6 hours for moderate sedation

For Fistulogram/Declotting

• Review current dialysis data: recent venous pressures, measured access flow (Qa), Kt/V trends
• Upper extremity duplex ultrasound of access if available — characterize anatomy, identify obvious stenosis or thrombus, confirm flow direction
• Physical examination of access: pulse (AVG), thrill, bruit, augmentation on compression, arm swelling, skin changes
• Cross-sectional imaging (CT venogram) if central vein stenosis is suspected — arm edema with preserved access thrill, prior ipsilateral subclavian catheter
• Contrast allergy preparation if applicable — patients on hemodialysis can receive contrast without concern for contrast-induced nephropathy (no residual renal function to protect); premedicate for allergy as needed
• Anticoagulation status: note antiplatelet agents; hold anticoagulation per protocol for declotting procedures

Procedure Overview

The following is a high-level summary. Full step-by-step technique, balloon sizing, declotting protocols, and central vein recanalization procedures are available in RadCall Pro.

Tunneled HD Catheter Placement

1. Ultrasound-guided IJV access — right IJV preferred; micropuncture technique preferred to minimize venous trauma; confirm venous (non-pulsatile, compressible) position before advancing wire
2. Wire advancement — advance wire to IVC under fluoroscopic guidance; confirm wire position in IVC (not arterial, not azygos)
3. Tunnel creation — create subcutaneous tunnel from exit site (anterior chest, lateral to sternum) to the IJV access site; tunnel direction and exit site position determine catheter lie; cuff positioned 1–2 cm from exit site to allow fibrous ingrowth
4. Catheter placement — dialysis catheters come in preset sizes; select the appropriate size based on patient anatomy and measured insertion length; introduce through peel-away sheath over wire; advance tip to RA-SVC junction or within right atrium — confirm tip position fluoroscopically; dialysis catheter tips sit deeper than CVL tips to achieve adequate flow rates
5. Hemostasis and closure — aspirate all lumens to confirm blood return; flush each lumen with heparin lock per protocol; secure catheter hub to skin; close venotomy site

Fistulogram

1. Access the AVF or AVG — micropuncture needle placed in the direction of arterial inflow (retrograde) or venous limb depending on segment of interest; digital subtraction angiography setup
2. Contrast injection and stenosis identification — opacify venous outflow from anastomosis to central veins; identify stenosis location, length, and severity; >50% reduction in luminal diameter relative to adjacent normal segment is hemodynamically significant
3. Balloon angioplasty of stenosis — high-pressure balloon (often 7–10 mm for venous outflow; match balloon diameter to reference vessel); inflate to nominal or rated burst pressure; hold 1–2 minutes; endpoints are <30% residual stenosis and restored flow
4. Assess anastomosis and arterial inflow — if outflow is patent and dysfunction persists, evaluate the arterial anastomosis and inflow artery for stenosis
5. Completion venogram — document residual stenosis, flow, and any procedural complications; achieve hemostasis at access site with manual pressure (longer for AVG — synthetic graft does not seal as readily as native vessel)

Declotting Thrombosed AVG (Pharmacomechanical Thrombolysis)

1. Dual access — micropuncture access into the venous limb and arterial limb of the graft; confirm position within graft lumen by gentle contrast injection
2. Clot maceration — mechanical thrombectomy device (Arrow-Trerotola percutaneous thrombolytic device, AngioJet rheolytic thrombectomy, or pulse-spray pharmacomechanical thrombolysis with tPA); macerate and aspirate clot throughout graft body
3. Arterial plug treatment — a fresh thrombus plug accumulates at the arterial anastomosis; a Fogarty balloon catheter is advanced past the plug, inflated, and withdrawn to pull the plug into the venous side of the graft where it can be morcellated and cleared with the thrombectomy device
4. Angioplasty of culprit stenosis — graft-vein anastomosis is the most common underlying lesion; balloon angioplasty to restore luminal patency; size balloon to match normal outflow vein diameter
5. Completion venogram — confirm restored flow through graft and into central veins; document residual stenosis; achieve hemostasis

AVF Maturation Assessment

AVF maturation requires remodeling of the outflow vein in response to increased arterial flow — this takes a minimum of 6 weeks and often 3–6 months. Premature cannulation causes irreversible damage to an immature vein and is a leading cause of AVF failure.

The "Rule of 6s" is the standard clinical benchmark for maturation: outflow vein diameter ≥6 mm, depth ≤6 mm below the skin surface (accessible for cannulation), and access flow (Qa) ≥600 mL/min — all assessed at minimum 6 weeks post-creation. Physical exam correlates include a palpable thrill throughout the access, soft and compressible vein segment, and absence of aneurysmal dilation or stenotic narrowing.

Failure to mature (FTM) occurs in 20–60% of AVFs, with higher rates in diabetics, women, and elderly patients. Early fistulogram at 6–8 weeks identifies treatable lesions:

• Juxta-anastomotic stenosis: most common cause of FTM; high-pressure balloon angioplasty has excellent technical success; may require 2–3 sessions over several weeks to achieve adequate dilation
• Accessory (competing) veins: branches that divert flow away from the main outflow vein, preventing dilation; coil embolization of accessory veins redirects flow and promotes maturation — identify on fistulogram by observing flow toward non-cannulable venous branches
• Inflow stenosis: less common; treat with angioplasty of arterial anastomosis or radial/brachial artery stenosis if present

Complications

Post-Procedure Care

Tunneled HD Catheter

• Confirm tip position on post-procedure chest radiograph before first use — tip should be at RA-SVC junction or within the right atrium
• Catheter can be used immediately after placement (vs. AVF which requires maturation)
• Exit site care: dry, clean dressing; change at each dialysis session; avoid immersion in water (shower with occlusive cover)
• Heparin lock or trisodium citrate lock per dialysis unit protocol after each use
• All catheter-dependent patients should have an active access plan — referral to surgery for AVF creation if not already in progress

AVF Angioplasty and Fistulogram

• Access may be used at the next scheduled dialysis session after angioplasty — document lesion treated and residual stenosis in procedure note
• Monitor access function at subsequent dialysis sessions: venous pressures, access flow measurements, physical exam
• Schedule surveillance duplex ultrasound every 3–6 months for AVF/AVG; elevated venous pressures or decreased access flow at dialysis should trigger repeat fistulogram

Post-PMT (Declotting)

• Access available for use same session or next scheduled dialysis — document thrombus burden, culprit lesion treated, and residual stenosis
• Recurrent thrombosis within weeks of declotting indicates undertreated stenosis — repeat fistulogram ± more aggressive angioplasty or stent placement
• Prolonged hemostasis at access sites after declotting — systemic anticoagulation or lytics used during procedure increase bleeding risk

When to Escalate

• Catheter-related bacteremia with S. aureus, fungi, or Pseudomonas — remove catheter; do not attempt salvage; echocardiogram to evaluate for endocarditis; infectious disease consultation; do not replace catheter until bacteremia is cleared (typically 72 hours of negative cultures)
• Central vein occlusion with failed angioplasty — venoplasty and stent-graft for recanalization; renal/vascular surgery consultation for surgical bypass; SVC reconstruction in selected cases; consider contralateral access if ipsilateral central vein is chronically occluded
• Steal syndrome with hand ischemia — urgent surgical consultation for DRIL (distal revascularization-interval ligation) or access banding; do not delay — ischemic neuropathy and tissue loss are irreversible
• Ruptured access or pseudoaneurysm — covered stent-graft if amenable to endovascular management; surgical consultation for complex rupture, infected pseudoaneurysm, or failed endovascular repair

KDOQI 2019 Access Guidelines — Summary

The KDOQI 2019 Clinical Practice Guideline for Vascular Access represents a major paradigm shift — moving away from the prior "Fistula First" mandate toward a patient-centered, individualized approach guided by the concept of the ESKD Life-Plan: a comprehensive, longitudinal map of dialysis modality and access strategy tailored to the individual patient's trajectory, life expectancy, and goals of care.^[1]

Core Philosophy: "Right Access, Right Patient, Right Time, Right Reason"

AVF and AVG are both preferred over CVCs, but the choice between AVF and AVG requires individualized clinical judgment — not a universal hierarchy. AVF is preferable when feasible because successful maturation is associated with fewer long-term vascular events and fewer interventions. However, AVG may be the better initial choice in patients at high risk of AVF nonmaturation — women, older patients, and those with peripheral vascular disease — given that AVF nonmaturation rates are 30–40%.^[3,4]

Timing of Access Creation

AVF Maturation Criteria

KDOQI defines a mature AVF as one that dependably delivers prescribed dialysis via 2-needle cannulation for ≥75% of sessions over a 4-week evaluation period.^[5] The traditional Rule of 6s (flow ≥600 mL/min, diameter ≥6 mm, depth ≤6 mm, assessed at 6 weeks) remains a practical clinical benchmark.^[6,7] Minimum ultrasound criteria at 4 weeks are vessel diameter 4–5 mm and blood flow 400–500 mL/min. In the US, average time to cannulation for successfully maturing AVFs is approximately 132 days; 35.9% of created AVFs fail to mature.^[1]

CVC Recommendations

• CVCs are associated with a 2- to 3-fold higher risk of infection-related hospitalization compared to AV access — minimize CVC use and duration whenever possible^[1]
• Target CRBSI rate: ≤1.5 infections per 1,000 CVC days^[1]
• Use chlorhexidine for exit site and catheter hub cleansing; minimize manipulation until exit site and tunnel are healed
• Designate only trained personnel for CVC access and maintenance; monitor for complications at each dressing change or dialysis session

Surveillance

KDOQI found insufficient evidence to recommend routine AVF/AVG surveillance by access blood flow measurement, pressure monitoring, or imaging for asymptomatic stenosis beyond routine clinical monitoring. Pre-emptive angioplasty of AVFs or AVGs with stenosis not associated with clinical indicators is not recommended.^[9] Intervene when clinical signs of dysfunction are present — elevated venous pressures, decreased flow rates, prolonged bleeding, or inadequate dialysis.

References

1. Lok CE, Huber TS, Lee T, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020;75(4 Suppl 2):S1–S164.
2. Rajan DK et al. Pharmacomechanical thrombolysis of thrombosed hemodialysis access grafts. J Vasc Interv Radiol. 2015.
3. Allon M, Young CJ, Lee T. Optimizing dialysis vascular access: moving beyond Fistula First. Clin J Am Soc Nephrol. 2026;21(3):506–514.
4. Lok CE, Huber TS, Orchanian-Cheff A, Rajan DK. Arteriovenous access for hemodialysis: a review. JAMA. 2024;331(15):1307–1317.
5. Huber TS, Berceli SA, Scali ST, et al. Arteriovenous fistula maturation, functional patency, and intervention rates. JAMA Surg. 2021;156(12):1111–1118.
6. ACR Appropriateness Criteria® Dialysis Fistula Malfunction. Expert Panels on Interventional Radiology and Vascular Imaging. J Am Coll Radiol. 2023;20(11S):S382–S412.
7. Nantakool S et al. Upper limb exercise for arteriovenous fistula maturation in haemodialysis access. Cochrane Database Syst Rev. 2022;10:CD013327.
8. Feldman HI et al. US renal data system: access use and patient outcomes. Am J Kidney Dis. 2003.
9. Lok CE, Moist L. KDOQI 2019 vascular access guidelines: what is new? Adv Chronic Kidney Dis. 2020;27(3):171–176.