Hemodialysis Vascular Access: AV Fistula, Graft, and Tunneled Dialysis Catheter Guide

Clinical guide to hemodialysis vascular access: AV fistula (preferred), AV graft, and tunneled hemodialysis catheter — indications, care, complications, the access hierarchy, and vessel preservation for CKD patients.

guide•Feb 2026•Central Venous Catheters

Hemodialysis Vascular Access: AV Fistula, Graft, and Tunneled Dialysis Catheter Guide

Hemodialysis requires vascular access capable of delivering blood flow rates of 300–450 mL/min to the dialysis circuit — far beyond what standard CVADs can provide. The choice and management of hemodialysis vascular access determines dialysis efficiency, patient quality of life, and complication risk. For vascular access clinicians, understanding the hemodialysis access hierarchy is essential because decisions about IV access in CKD and ESRD patients must account for future dialysis access needs.

Parent guide: Central Venous Catheters: Complete Clinical Reference

The Hemodialysis Access Hierarchy

Clinical guidelines (KDOQI 2006, 2019 update; DOPPS data) establish a clear preference hierarchy for hemodialysis access:

1. Arteriovenous (AV) Fistula — strongly preferred

  • Native vessel; lowest infection rate; longest survival
  • Requires 6–12 weeks of maturation before use
  • Requires adequate pre-existing arterial and venous anatomy

2. AV Graft — second choice

  • Synthetic conduit (polytetrafluoroethylene, PTFE); faster to use than fistula (2–6 weeks)
  • Higher infection and thrombosis rates than fistula
  • Option when native vessel anatomy inadequate for fistula

3. Tunneled Hemodialysis Catheter — third choice, bridge access

  • Immediate use; no maturation
  • Highest infection rate of any dialysis access type
  • Intended as bridge to definitive access (fistula or graft), not permanent solution
  • Some patients with contraindications to surgical access remain catheter-dependent

AV Fistula

What It Is

An AV fistula (AVF) is created surgically by anastomosing an artery to an adjacent vein, typically in the non-dominant forearm or upper arm. The resulting high-flow venous conduit enlarges (matures) over weeks to months, becoming suitable for dialysis needle cannulation.

Common sites:

  • Radiocephalic (forearm): Radial artery to cephalic vein at the wrist. Classic “Brescia-Cimino” fistula; requires adequate cephalic vein diameter (≥2.5 mm) and radial artery caliber.
  • Brachiocephalic (upper arm): Brachial artery to cephalic vein at antecubital fossa. Higher flow, suitable when forearm veins are inadequate.
  • Brachiobasilic: Brachial artery to transposed basilic vein. Requires surgical transposition; suitable when cephalic vein is absent or damaged.

Maturation

  • Target: AVF diameter ≥6 mm, flow ≥600 mL/min, with adequate depth for cannulation (≤6 mm from skin surface)
  • Timeline: 6–12 weeks in most patients; may be longer in diabetics, women, and older patients
  • Assessment: Clinical palpation (thrill), auscultation (bruit), duplex ultrasound

Why This Matters for Vascular Access Clinicians

The arm bearing an AV fistula must never have a PICC, peripheral IV, or blood pressure cuff applied. Vascular access procedures in the fistula arm can cause:

  • Thrombosis of the fistula (loss of dialysis access)
  • Compression of the fistula (reduced flow, thrombosis)
  • Steal phenomenon exacerbation

Pre-dialysis access planning: In patients with CKD Stage 3–5 approaching dialysis, the upper extremity veins (particularly cephalic and basilic veins) are preserved as future fistula creation sites. PICCs and midlines placed in these patients consume this vascular capital, potentially eliminating future fistula options.

Practice implication: Every IV access order in a CKD patient requires knowing: Is this patient expected to require dialysis? If yes, do not place a PICC in the arm without nephrology consultation.

AV Graft

What It Is

An AV graft uses a synthetic conduit (usually PTFE) to bridge between an artery and a vein. The graft is placed subcutaneously and matures with fibrous encapsulation within 2–6 weeks, then is cannulated with dialysis needles directly through the skin and graft material.

Indications:

  • Inadequate native vein diameter or anatomy for AVF
  • Previous failed fistula
  • Need for earlier access than AVF maturation allows (relative; TDC is still faster)

Comparison to AVF:

  • Higher thrombosis rate (graft thrombosis rate 2–3× higher than AVF)
  • Higher infection rate (synthetic material, less resistance to bacteremia)
  • Shorter device lifespan

Tunneled Hemodialysis Catheter (TDC)

What It Is

A tunneled dual-lumen catheter specifically engineered for high-flow hemodialysis access. Distinguished from standard CVADs by:

  • Large bore: 12–14 French (much larger than standard CVCs)
  • High flow design: Arterial and venous lumens separated to minimize recirculation
  • Tip configuration: Split-tip or step-tip designs to achieve separation between blood withdrawal and return lumens
  • Tip position: Right atrium or IVC/RA junction (deeper than standard CVAD tip) for optimal flow rates

Tip Position (Different from Standard CVADs)

Unlike standard CVADs where RA position is undesirable, TDC tips are positioned at or just below the cavoatrial junction, often with the tip in the right atrium, to achieve adequate blood flow rates. The large caliber and high-flow requirements necessitate this deeper positioning.

Indications for TDC

  • Bridge to AVF or graft maturation: Patient starting dialysis before fistula is ready
  • Fistula or graft failure: Acute thrombosis requiring emergency dialysis access
  • Dialysis access not feasible surgically: Patient without adequate vessels for fistula or graft (rare long-term TDC-dependent patients)
  • Hospice/end-of-life: When long-term surgical access is not warranted

Care and Maintenance

TDC care requires strict ANTT at every access given the extreme infection risk:

  • Access only by trained dialysis nursing staff — TDCs are NOT general nursing access devices
  • Never use TDC for general IV medications or blood draws — TDC lumens are designated exclusively for hemodialysis except in emergencies
  • Heparin lock (per dialysis unit protocol): typically high-concentration heparin (5,000 units/mL, 1.5–1.8 mL per lumen) to fill dead space and prevent clotting during interdialytic interval
  • Exit site care per institutional protocol (typically at each dialysis session)

CLABSI Risk

TDCs have the highest CLABSI rate of any CVAD type (3–7 per 1,000 catheter-days vs. 0.5–2 for PICCs). The high-risk profile reflects:

  • Frequent access (3× weekly)
  • High-flow manipulation
  • Patient population vulnerability (ESRD patients are immunocompromised)
  • Large lumen diameter

Infection with TDC is a medical emergency. TDC-related bacteremia carries high mortality; common pathogens include Staphylococcus aureus, coagulase-negative staphylococci, gram-negative rods, and Candida. Prompt blood cultures and antibiotic initiation are required.

Vessel Preservation: The Non-Dialysis Clinician’s Responsibility

The most important contribution a non-dialysis vascular access clinician can make to hemodialysis access care is vessel preservation:

Never place in ESRD or advanced CKD patients without nephrology consultation:

  • PICC or midline catheter in either arm
  • Subclavian CVC (subclavian stenosis from catheterization permanently eliminates ipsilateral fistula options)

Preferred alternatives for central access in ESRD patients:

  • Internal jugular CVC (less subclavian vein injury than subclavian approach)
  • Femoral CVC for short-term access (high CLABSI risk but does not damage arm veins)
  • Groin access for emergent situations

Blood pressure measurement: Avoid blood pressure measurement in the fistula arm; contralateral arm or leg cuff preferred.

Phlebotomy: No venipuncture in the fistula arm. No blood draws from AVF or graft.

Related guides:

Related policies:

References

  1. KDOQI Clinical Practice Guidelines for Vascular Access. (2006). Am J Kidney Dis, 48(Suppl 1):S176–S247.
  2. Lok CE, et al. (2020). KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis, 75(4 Suppl 2):S1–S164.
  3. Gorski LA, et al. (2021). INS Infusion Therapy Standards of Practice. J Infus Nurs, 44(Suppl 1).
  4. Moist LM, et al. (2012). Optimal hemodialysis vascular access in the elderly patient. Semin Dial, 25(6):640–648.