September 2004
Sponsored by:
P0105/0379
The Dudley Group of Hospitals NHS Trust
Patient Information for Haemodialysis
The Arteriovenous Graft
For Haemodialysis
Author. S. Veerabudren
The Arteriovenous Graft - Help line Advice
Time
Telephone Number
Advice
Day time
07:30 - 21: 00
01384-244 384
Ask to speak to
Haemodialysis staff.
01384-456 111
(Russell's Hall
Hospital Switchboard)
Tell switchboard you are a
Renal patient.
Night time
21:00 - 07: 30
Ask to speak to on call
Haemodialysis staff.
• Your Graft is your lifeline. Please look after it.
References
1. BROUWER D J, (1995) Cannulation Camp:basic cannulation training for haemodialysis staff.
Dialysis and Transplantation. 24 (11) pp. 606-611.
2. IMPRA Vascular Education Service Library, (1996) P.O. Box 1740, Tempe. Arizona
85280-1740.
3. Dialysis Outcomes Quality Initiatives (DOQI) @www.kidney.org.
copyrighted by author
15.
Jargon Explained
Access:
The term used to describe the site where you are
connected to the dialysis machine
Anaesthetic:
The drug used to numb the area of needle puncture
Arterial:
The needle which is used to draw blood away from the graft
Artery:
The blood vessel that carries blood from the heart to parts
of the body
Bruit:
The sound of blood flowing in the graft
Cannulation:
The insertion of needles into the graft for dialysis
Dialyser:
The artificial kidney
Fistula:
The arteriovenous fistula is the joining of the natural artery
to a natural vein to create a new blood access for dialysis
Graft:
A synthetic or natural material used for vascular access
for dialysis
Haemodialysis: The purification of blood by passing it over a special
membrane to remove waste material and toxins
Graft:
A synthetic or natural material used for vascular access
for dialysis
PTFE:
Poly-tetra-fluoro-ethylene. A type of man- made medical
grade plastic
Millilitre (ml):
A measurement of fluid (1 litre = one thousand millilitres.)
(A can of drink contains 300 ml.)
Nephrologist:
A doctor who specialises in kidney diseases
Thrill:
The feel of the trembling movement in the graft
Vein:
Blood vessel which returns blood from parts the body to
the heart
Venous:
The needle used to return blood to the heart
14.
The information contained in this booklet is aimed at the
following groups of patients:
• Patients waiting to go on the Haemodialysis programme.
• Patients with a temporary /permanent catheter already
having Haemodialysis.
• Patients on Continuous Ambulatory Peritoneal Dialysis
programme (C.A.P.D.) transferring to haemodialysis.
• Patients waiting for another permanent vascular access.
Please note that the information in this booklet is only a guide.
Further information can be obtained from the Renal Unit Staff.
Contents
Page 1.
Introduction
Page 2.
What is a graft
Page 3.
Why do I need a graft
Page 4.
Where is the graft placed
Page 6.
How is it done
Page 7.
Graft Care
Page 10.
Advice in emergency situations
Page 13.
Frequently asked questions
Page 14.
Jargon explained
Page 15.
Help line
Frequently Asked Questions
Question
Answer
Can I walk normally after the leg graft surgery?
Yes. The renal staff will advise you how soon after surgery
Question
Answer
Can I jog and do exercise with a leg graft?
Yes. As long as you have been advised by the renal staff.
Question
Answer
Can I wear tights on the leg graft?
Yes. Do not wear support tights or compression type
bandages.
Question
Answer
Can I shave my leg with the graft?
Yes. Please avoid getting close to the graft area.
Question
Answer
Can I drive?
Yes. Please carry a pack of gauze dressing and tape with
you whenever you travel.
Question
Answer
Can I swim?
Yes. Please swim in a properly managed pool and in
the sea.
Question
Answer
Can I do weight lifting with the graft arm?
No. It is not advisable.
13.
Some of the risks associated with your graft
As with all operations, there are certain risks involved .It is our aim to reduce
these risks as much as possible.
Below are some of the complications that can happen with the graft.
• Temporary and /or partial loss of feeling in the fingers.
• The hand with the graft may feel colder than the other one.
• The skin colour of the hand or fingertips may be paler.
• The blood vessels in the graft arm will increase in size over a
period of time.
• Occasionally, you may feel sharp pain in the graft.
• The graft may clot and it may become unusable for dialysis.
• The graft may bleed profusely after needles have been removed.
• A small swelling can appear anywhere on the graft. This can
happen due to repeated cannulation and weakness of the
graft material.
• The graft could become inflamed and the area around it could
become inflamed and hot to touch.
The renal team is always available for advice.
The haemodialysis staff will always do their best to ensure that your
graft deserves the best of attention and care.
May we reassure you that all our practices are based upon years of
experience and research methods practised around the world.
12.
Introduction
Patients suffering from Chronic Kidney Disease (CKD) have lost the normal
functions of their kidney or kidneys. Usually the kidneys filter blood and
remove waste produced by the bodily activities.
In renal failure, the waste produced by your body stays in the blood and
cannot be removed by the affected kidneys. The build -up of these toxic
substances can be fatal, if you are not treated. One way of removing those
nasty substances is to connect you to an artificial kidney machine. This
process is called Haemodialysis.
Haemodialysis is the passage of blood over a special membrane of the
artificial kidney (dialyser). The dialyser filters out most of the waste and the
purified blood is then returned to you.
In order all of this means that in order to be connected to the dialysis
machine, you require a link (access). This is a way of getting to the
blood stream.
The arteriovenous graft is one form of access. To achieve an adequate
dialysis, a minimum blood flow of 200 milli-litres of blood (about a cupful)
must flow through the dialyser per minute. In order to maintain a good
balance, you will need to be dialysed two or three sessions a week for an
average of four hours each session.
The arteriovenous graft is explained in more detail in the next few pages.
1.
What is a graft?
The Arteriovenous Graft
The graft is a type of access to the blood vessels. It allows you to be
dialysed regularly. It is the second most suited access for long-term
haemodialysis.
The graft is a length of specially treated type of plastic tubing. It is very soft
and pliable. This material has been produced specially to be placed inside
the human body. It has virtually no reaction to the human tissue. There are
two designs of graft, One is straight and the other is a loop. (Fig. 1.)
The looped graft has a special re-enforced ring to prevent it from kinking.
One end is sutured to an artery and the other is sutured to a vein to form a
loop. A straight length of graft can also be used (see Fig. 1).
The P.T.F.E (Polytetrafluoroethylene) graft has been in use for the last thirty
years in renal units around the world.
Fig. 1 Straight and Loop Grafts
2.
Graft bleeds out of control
If your Graft bleeds out of control:
• Hold on to the bleeding point by wrapping your other hand
around it.
• Hold it tight and call someone for help.
• Try to keep calm so that you can think straight.
If no one is around, dial 999 and say that you are a dialysis patient and you
have a bleeding artery in the arm.
• Sit down and wait for the ambulance.
• If someone is with you, advise the person to contact the Renal
Unit immediately.
What to do if the graft becomes hot and inflamed
and you have a temperature?
Contact the unit as soon as possible
Time
Telephone Number
Advice
Daytime
07:30 - 21: 00
01384-244 384
Ask to speak to
Haemodialysis staff.
Night time
21:00 - 07: 30
01384-456 111
Tell switchboard you are a
Renal patient.
Ask to speak to on call
Haemodialysis staff.
11.
Advice in emergency situation
Graft flow is slower or Buzz is weaker/stopped.
If at any time, you feel that there is a change in the graft buzz, contact the
unit immediately (number below). A change in the buzz may indicate that the
flow is getting poorer. This is why the buzz becomes weaker.
What to do in the mean time?
• Wrap the arm in a warm towel.
• Be prepared to come to hospital soon after the call.
10.
Why do I need a graft?
The nephrologist would have discussed with you the reasons why you require
a graft.
The three main ways to dialyse someone long-term is to use an
arteriovenous fistula, a haemodialysis catheter or a graft. The fistula is a
natural way of joining an artery to a vein. If your blood vessels are too small,
too far apart or affected in any way, the graft is then the best choice. The
catheter is used in individuals who have problems with blood vessels in the
arm or leg. Without an access you cannot be dialysed.
Each individual is assessed for the best-suited option.
3.
Where is the graft placed?
The graft is usually created in the arm. The ideal site is in the forearm area. It
can also be created in the upper arm or in the leg.
Fig.2a. Straight graft in the arm and leg
Femoral
vein
Median
basilic
vein
PTFE graft
Radial
artery
4.
Popliteal
artery
DON`T
• Wear tight sleeves above the graft. This may obstruct the
circulation to the graft. Prolonged obstruction can cause the
graft to clot.
• Lift heavy objects or bags with the graft arm.
• Allow anyone to take blood or put needles in your graft except
Renal Unit staff.
• Keep the arm raised above the head for prolonged periods
(working on ceilings). This will reduce the circulation in the
graft and may cause clotting.
• Allow blood pressure to be taken on this arm.
• Scratch or pick scabs from the needle puncture sites
9.
Graft Care
Once the graft has been inserted, great care must be taken to make sure
that it is functioning well and will last. This means that the buzz must be
strong .The renal unit staff would have explained this to you prior to
the operation.
Here are some tips to help you look after your graft
We call them, the DO and the DON`T
DO
• Feel the thrill of the graft as often as you can, especially before
bedtime and after. This will tell you how strong the blood flow is.
• Listen to the buzz of the graft by placing it next to the ear. Wear a
well-padded dressing around the graft to protect it from knocks in
the first few weeks
• Wear gloves in cold weather to keep the hand warm. It will also
increase circulation. This will reduce the risk of fingertips
getting cold.
• Wear gloves when doing gardening. They will protect from
scratches and cuts, which may cause infection.
• Carry packs of gauze dressing and a roll of tape in the car when
travelling, just in case the graft bleeds after a dialysis session.
• Inform the unit whenever you have a fever.
• Inform the unit if the graft becomes unusually painful, inflamed and
hot to touch.
• Inform the unit if any discharge comes from the graft.
Contact the unit if you have any questions about the graft
• Always use a protective leather pad or thick cloth on the graft arm
when working in hazardous areas
8.
Fig.2b. Loop graft in the arm and leg
Femoral
Artery
Femoral
vein
Median
basilic
vein
Brachial
artery
PTFE
loop
5.
How is it done?
The graft is inserted in the operating theatre. The procedure can be
performed by the vascular surgeon. The operation can be carried out under
local anaesthetic or general anaesthetic, depending on your general health at
the time.
With local anaesthetic, the blood vessels tend to remain the same size during
the procedure. Under general anaesthetic, the blood vessels become slightly
smaller during the operation. This can make the procedure more difficult.
Sometimes it is generally difficult to work with the blood vessels, which are in
poor condition.
A small cut of about 6cms (2ins.) is made in the skin where the graft is to be
inserted. The surgeon then assesses which are the better vessels to be
used. Another cut (2 in.) is made on the side of the artery and the vein. A
tunnel is created to thread the graft into the tissues. This will help to keep the
graft steady when the wound is healed up.
One end of the graft is sutured to the side of the artery and the other end is
sewn to the side of the vein. Once the clamps are open, the blood starts to
flow straight into the graft.
A larger volume of blood can now flow from the artery directly into the vein. It
is this shortcut which makes the graft buzz and vibrate when touched.
The surgeon tests for the blood flow whilst you are still in theatre. On return
to the ward, you will be able to feel the thrill or listen to the buzz of the graft.
This means that it is already working. The operation may take up an hour or
so. The renal nurse will explain to you how to care for your graft.
6.
How long does the graft last?
The life span of a graft depends upon each individual's general health. No
one can predict how long it will last. Generally, a trouble-free graft can last up
to ten years. If and when the graft fails, then attempts will be made to place
another one in either the same arm or the other arm. It can also be placed in
the leg.
With every operation, there are always some risks. No one can guarantee
how well the graft will perform. If a graft fails, there is an opportunity for
another to be formed. This will also depend on how good the other blood vessels are in the arms or legs.
If all fails, then there is the possibility of a long-term catheter being used. This
catheter is inserted in the neck vein. More details of this type of access can
be obtained from the renal unit.
How are the needles put in the graft?
After a period of three to eight weeks, the graft will be ready to use for
dialysis. This means that the graft can be cannulated using two fistula
needles (fig.3 & 4). For the arm graft, the venous needle is usually placed
pointing to the shoulder. The arterial needle is placed pointing towards the
wrist. Sometimes both needles may point towards the shoulder.
You may have a small amount of local anaesthetic before the cannulation
procedure. The same procedure applies for the leg graft. The venous needle
is placed pointing towards the groin and the other can be pointing either
towards the groin or the foot. These are small variations that can be done
according to the blood flow.
Fig.3 Needles in an arm graft
Fig.4 Needles in a leg graft
7.