Last reviewed: March 2026
Contents
MDM Templates
Fistula Pain / Dysfunction
Patient with ESRD on hemodialysis presents with pain and concern for dysfunction of their AV fistula. On exam the fistula does not demonstrate signs of active bleeding, expanding hematoma, frank infection, aneurysmal dilation, or distal limb ischemia. Augmentation test and arm elevation test were performed to assess for inflow and outflow obstruction.
History and exam lower suspicion for fistula thrombosis with complete occlusion, infected pseudoaneurysm, steal syndrome with limb-threatening ischemia, or hemorrhage. Presentation is most concerning for fistula stenosis / dysfunction requiring further evaluation.
Plan: Ultrasound of fistula to evaluate flow and patency.
Disposition: If confirmed stenosis or thrombosis, admit for IR fistulogram with possible intervention and temporary dialysis catheter placement. If patent with preserved flow, discharge with urgent vascular surgery follow-up within 24-48 hours and next scheduled dialysis session.
Fistula Bleeding
Patient with ESRD on hemodialysis presents with bleeding from their AV fistula site. On exam there is no evidence of expanding hematoma, pseudoaneurysm rupture, surrounding infection, or distal limb ischemia.
History and exam lower suspicion for coagulopathy-driven hemorrhage requiring systemic intervention, pseudoaneurysm rupture, or fistula infection with erosion.
Plan: Direct pressure applied for 15+ minutes with hemostasis achieved. Topical thrombin applied. Uremia assessed — if BUN significantly elevated, DDAVP 0.3 mcg/kg IV considered for platelet dysfunction.
Disposition: Discharge with return precautions for recurrent bleeding, expanding swelling, or signs of infection. Follow up with vascular surgery and at next dialysis session.
If bleeding not controlled with pressure:
Consult vascular surgery emergently. Consider Dermabond for puncture site oozing. Tourniquet proximal to site only as temporizing measure with close monitoring of distal perfusion.
Fistula Infection
Patient with ESRD on hemodialysis presents with erythema, warmth, and tenderness overlying their AV fistula. On exam there is no evidence of active hemorrhage, expanding hematoma, pseudoaneurysm rupture, or distal limb ischemia. No fluctuance to suggest drainable abscess.
History and exam are consistent with cellulitis overlying the fistula without systemic toxicity. History, exam, and presentation lower suspicion for septic thrombophlebitis, infected pseudoaneurysm requiring surgical intervention, or endocarditis.
Simple cellulitis, non-toxic:
Plan: Oral antibiotics with MRSA coverage (TMP-SMX DS BID + cephalexin 500 mg QID).
Disposition: Discharge with vascular surgery follow-up within 24-48 hours for wound recheck. Return precautions for worsening redness, fever, or purulent drainage.
HD catheter infection or toxic-appearing:
Plan: Vancomycin 20 mg/kg IV (dosed to trough). Add gentamicin if gram-negative coverage needed.
Disposition: Admit. Vascular surgery consult for possible catheter removal or exchange.
Clinical Education
Fistula Physical Exam
A good fistula exam takes 60 seconds and tells you almost everything. Palpate for thrill (continuous vibration = patent, pulsatile without thrill = outflow obstruction). Listen with stethoscope for bruit quality. Then two maneuvers:[1]
| Test | How | What It Tests |
| Augmentation test | Occlude fistula downstream of anastomosis | Segment between occlusion and anastomosis should become hyperpulsatile = normal inflow |
| Arm elevation test | Raise arm above heart level | Fistula should collapse = normal outflow. Persistent distension = outflow obstruction |
Adequate fistula characteristics for use: Diameter >6 mm, depth 600 mL/min (“rule of 6s”).[1]
Stenosis and Thrombosis
Stenosis is the most common cause of fistula dysfunction and is the precursor to thrombosis. Outflow stenosis presents as persistent distension on arm elevation and hyperpulsatility without occlusion. Inflow stenosis presents as a flat, difficult-to-palpate fistula with weak augmentation.[2]
Acute thrombosis presents as sudden loss of thrill and bruit with a firm, non-compressible fistula. This is time-sensitive — refer urgently to IR for thrombectomy or thrombolysis. Success rates decline after 48 hours. The patient will need a temporary dialysis catheter if they cannot wait for fistula restoration.[2]
Steal Syndrome
Steal syndrome occurs when the fistula diverts enough arterial blood to cause distal ischemia. Classic presentation: hand pain, coolness, pallor, or paresthesias that worsen during dialysis. Severe cases can cause digital gangrene. More common with brachial artery-based fistulas than radial.[3]
Bedside test: Occlude the fistula manually — if distal symptoms improve and perfusion returns, steal is confirmed. Refer to vascular surgery for banding, DRIL procedure (distal revascularization-interval ligation), or fistula ligation in severe cases.[3]
Bleeding Management
Direct pressure for 15-20 minutes is first-line. Most post-dialysis bleeding stops with sustained pressure. If not, apply topical thrombin with pressure. Dermabond can seal puncture sites. Check for uremia (elevated BUN) contributing to platelet dysfunction — DDAVP 0.3 mcg/kg IV improves platelet function within 1 hour and lasts 6-8 hours.[4]
Never clamp an AV fistula — this risks thrombosis. Never place a BP cuff on the fistula arm. If tourniquet is needed for life-threatening hemorrhage, it is a temporizing bridge to vascular surgery.
Infection Approach
AV fistula infections are less common than graft infections but carry significant morbidity. Native fistula cellulitis can often be managed outpatient with oral antibiotics and close follow-up. Graft infections almost always require admission, IV antibiotics, and surgical evaluation.[5]
HD catheter infections are the most common vascular access infection. Vancomycin is first-line (covers MRSA, dose at dialysis). Add gram-negative coverage (gentamicin or cefepime) if the patient is septic. Catheter removal or exchange is often necessary for persistent bacteremia.[5]
References
- Beathard GA. Physical Examination of the Dialysis Vascular Access. Semin Dial. 1998;11(4):231-236. PubMed
- KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020;75(4 Suppl 2):S1-S164. PubMed
- Tordoir JH et al. Prospective Evaluation of Failure Modes in Autogenous Radiocephalic Wrist Access for Haemodialysis. Nephrol Dial Transplant. 2003;18(2):378-383. PubMed
- Mannucci PM. Desmopressin (DDAVP) in the Treatment of Bleeding Disorders. Blood. 1997;90(7):2515-2521. PubMed
- Allon M. Dialysis Catheter-Related Bacteremia: Treatment and Prophylaxis. Am J Kidney Dis. 2004;44(5):779-791. PubMed
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