Diagnosis and Management of Hemodialysis Access Complications

Importance: More than 100 000 patients in the US begin hemodialysis each year. While arteriovenous fistulas (AVFs) have been the preferred dialysis access due to their durability and lower complication rates, contemporary guidelines now emphasize achieving a functional access tailored to individual patient needs. Prosthetic arteriovenous grafts (AVGs) remain a critical alternative for patients with suboptimal autogenous options. Given the essential role of hemodialysis access in patient survival, both surgeons and nonsurgeons must be familiar with the unique challenges of placing and maintaining AVFs and AVGs. This review highlights common complications associated with each access type and evidence-based management strategies. Observations: Complications of arteriovenous (AV) access can manifest at varying time points, ranging from the immediate postoperative period to months or years later due to long-term sequelae of altered hemodynamics and repeated cannulation. Determining whether symptoms, such as pain, weakness, paresthesia, and hand dysfunction, are due to the AV access or simply due to outcomes of kidney failure can be extremely challenging, emphasizing the importance of a detailed patient history, comprehensive physical examination, and duplex imaging. Certain complications, including access-related hand ischemia (ie, steal syndrome), carpal tunnel syndrome, ulnar neuropathy, aneurysms, and pseudoaneurysms, have multiple treatment options that span conservative management, open surgery, and endovascular procedures. Treatment decisions should consider patient comorbidities, anatomical factors, the risk of access site loss, and the availability of alternate access sites. Other complications, such as ischemic monomelic neuropathy, persistent bleeding, and high-output heart failure, require urgent intervention to prevent loss of limb or life. Conclusions and Relevance: Patients with upper-extremity AVF and AVG can face a number of access-related complications. Understanding the diagnostic evaluation and treatment options is essential to balance preserving access longevity while minimizing the risk of short and long-term morbidity and mortality.