How urgent is the need for treatment when my fistula stops working?

Acute fistula thrombosis should be assessed and treated within 72 hours — after this point the clot organises, the vessel wall contracts, and surgical salvage becomes significantly less likely to succeed. Contact your renal access team or vascular surgeon immediately if your fistula thrill disappears.

What is the most common cause of AV fistula failure requiring revision?

Venous outflow stenosis from neointimal hyperplasia — most commonly at the venous anastomosis or in the first few centimetres of the outflow vein — is responsible for 70 to 80% of fistula failures. This progressive narrowing develops silently over months and is detected early only by routine duplex surveillance.

Can percutaneous balloon angioplasty replace surgical revision?

Percutaneous transluminal angioplasty (PTA) is effective for short, focal stenoses and achieves similar initial success to surgical patch angioplasty with less anaesthetic risk and no wound. However, surgical revision provides longer durability for extensive or recurrent stenoses, and should be considered after two failed PTA attempts at the same site.

How do I prevent my fistula from failing again after revision?

Strict rotation of cannulation sites at every dialysis session distributes needle trauma evenly and is the most important needle-related preventive measure. Avoid compression of the fistula arm, maintain optimal fluid balance to prevent intradialytic hypotension, and attend all scheduled duplex surveillance appointments to detect developing stenosis before re-thrombosis occurs.

What happens if the fistula cannot be salvaged despite revision?

If surgical revision fails or the fistula is not anatomically suitable for further reconstruction, the next step depends on the available vascular capital — typically a more proximal brachiocephalic or brachiobasilic fistula, or a synthetic AV graft if no further native vessels are available. A temporary tunnelled dialysis catheter provides access during the transition.

Dialysis Access Maintenance

Dialysis Access Maintenance Surgery preserves and prolongs the function of an existing haemodialysis AV fistula or graft through surgical thrombectomy, patch angioplasty, or interposition revision — avoiding the need to create new access and protecting the patient's limited vascular capital for future dialysis access.

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Overview

Dialysis Access Maintenance Surgery addresses the complications — thrombosis, stenosis, pseudoaneurysm, infection, or non-maturation — that threaten the function of an existing AV fistula or synthetic graft, through surgical revision techniques that restore or maintain adequate blood flow for effective haemodialysis. Preserving existing access is always the most cost-effective and patient-centred approach, as each revision extends the functional life of the access and protects the limited venous capital of dialysis patients. The surgical techniques employed include thrombectomy, patch angioplasty, vein transposition, and interposition graft repair — all designed to restore the access to its optimal function with the minimum sacrifice of future access options.

Types of Dialysis Access Maintenance

Access maintenance encompasses surgical and endovascular techniques applied to fistulas and grafts depending on the mechanism of dysfunction.

Surgical Thrombectomy (clot removal from recently thrombosed fistula or graft)
Patch Angioplasty (surgical widening of stenotic segment)
Angioplasty and Stenting (percutaneous balloon and stent for venous stenosis)
Pseudoaneurysm Repair (surgical repair of the access wall bulge from repeated needle trauma)
Infected Graft Excision with New Access Creation (definitive management of infected synthetic graft)

Risk Factors for Access Dysfunction

Fistula and graft dysfunction result from specific mechanisms that reduce blood flow and shorten access lifespan.

Neointimal hyperplasia causing progressive venous outflow stenosis
Repeated needle trauma to the same access segment causing pseudoaneurysm
Hypotension during dialysis causing access thrombosis from reduced flow
Central venous stenosis from previous catheter use limiting outflow
Inadequate antiplatelet therapy increasing access thrombosis risk
Infection of synthetic graft material requiring access removal

Access Failure Symptoms and Indications

These signs indicate that the existing dialysis access is failing and requires urgent assessment and maintenance intervention.

Loss of thrill or bruit on palpation or auscultation of the access
High venous pressure alarms during dialysis indicating outflow stenosis
Poor blood flow rates reducing dialysis adequacy
Prolonged bleeding after needle removal
Visible pseudoaneurysm bulge on the access
Complete thrombosis requiring urgent thrombectomy within 72 hours
Swelling of the access arm from venous hypertension
Fever with access site tenderness suggesting graft infection

Key Benefits

Discover the advantages of choosing our dialysis access maintenance services.

Salvages the existing fistula protecting the patient's limited future vascular access capital

Avoids the need for new access creation and temporary catheter use during healing

Most patients resume haemodialysis through the revised access within 24 to 72 hours

Duplex surveillance planned at 4 to 6 weeks to confirm sustained post-revision patency

Preserves the patient's best permanent access and avoids inferior alternative access types

Clinical Features

The technology, techniques and clinical approach behind our dialysis access maintenance.

Complete duplex and fistulogram assessment maps the exact failure mechanism before any surgery

Fogarty catheter thrombectomy in both directions retrieves all accessible thrombus from the access

Surgical correction technique tailored to the specific stenosis mechanism identified on imaging

Intraoperative duplex confirms haemodynamically adequate flow velocity after revision

Dialysis team informed immediately after revision for same-day or next-day dialysis scheduling

Preparation Instructions

After Access Maintenance Surgery, protect the revised access from compression and rotate cannulation sites carefully to prevent recurrent damage to the same segment. Attend follow-up duplex surveillance at 4 to 6 weeks and report any decrease in thrill, access difficulty during dialysis, or arm swelling to your renal team immediately. Take prescribed antiplatelet medications consistently and maintain optimal fluid balance to avoid hypotensive episodes during dialysis that increase access thrombosis risk.

The Procedure

Step-by-step guide to what you can expect during your dialysis access maintenance procedure.

Access Dysfunction Assessment and Fistulogram
Your vascular access surgeon reviews the duplex ultrasound and fistulogram to characterise the precise location and mechanism of dysfunction — whether anastomotic stenosis, mid-vein stenosis, perianastomotic pseudoaneurysm, or complete thrombosis — before selecting the most appropriate revision technique.
Anaesthesia and Fistula Exposure
Local or regional anaesthesia is administered and the entire length of the dysfunctional access is prepared in a sterile manner. The operative approach is tailored to the identified problem — small incisions for anastomotic revision, longer incisions for thrombectomy of an extended thrombosed segment.
Thrombectomy When Thrombosis Is Present
For acute or subacute fistula thrombosis, a venotomy is made over the thrombus and a Fogarty embolectomy catheter is passed in both directions to retrieve all accessible clot. The extracted thrombus is inspected for underlying stenosis that caused the original thrombosis.
Surgical Correction of the Causative Stenosis
The underlying stenotic segment is addressed — vein patch angioplasty widens a focal stenosis, interposition vein or PTFE graft bridges a resected segment, and anastomotic revision corrects inflow stenosis. The correction is designed for maximum durability with minimum sacrifice of future access options.
Duplex and Flow Confirmation
A hand-held Doppler confirms strong fistula thrill and antegrade venous flow after all surgical corrections are complete. Intraoperative duplex imaging confirms the flow velocity and absence of residual haemodynamic stenosis before wound closure.
Wound Closure and Early Dialysis Planning
Wounds are closed with absorbable sutures and a light protective dressing applied. The dialysis unit is informed and most patients resume dialysis through the revised access within 24 to 72 hours. Duplex surveillance at 4 to 6 weeks confirms sustained improvement.

What to Expect

Dialysis Access Maintenance Surgery is performed under local or regional anaesthesia and takes 60 to 90 minutes depending on the complexity of the revision required. The problem segment is exposed, corrected using the most appropriate surgical technique — thrombectomy, patch, or interposition — and flow through the revised access is confirmed by palpation of a strong thrill and intraoperative Doppler before wound closure. Most patients resume haemodialysis through the maintained access within 24 to 72 hours.

Dialysis Access Maintenance

Overview

Types of Dialysis Access Maintenance

Risk Factors for Access Dysfunction

Access Failure Symptoms and Indications

Key Benefits

Clinical Features

Preparation Instructions

The Procedure

Access Dysfunction Assessment and Fistulogram

Anaesthesia and Fistula Exposure

Thrombectomy When Thrombosis Is Present

Surgical Correction of the Causative Stenosis

Duplex and Flow Confirmation

Wound Closure and Early Dialysis Planning

What to Expect

Frequently Asked Questions

Related Services

Thrombectomy Bypass

AV Fistula

Carotid Endarterectomy

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