What is the management approach for an inflamed arteriovenous (AV) fistula after hemodialysis (HD) management?

Management of Inflamed Arteriovenous Fistula After Hemodialysis

When an arteriovenous (AV) fistula becomes inflamed after hemodialysis, the fistula should be rested until swelling resolves completely, with appropriate antibiotic therapy initiated immediately if infection is suspected. 1

Initial Assessment and Management

• Evaluate for signs of infection including erythema, warmth, tenderness, purulence, or systemic symptoms (fever, chills) 1
• If infection is present, immediately initiate broad-spectrum antibiotic therapy with vancomycin plus an aminoglycoside, later adjusted based on culture results 1
• Complete antibiotic course should be 6 weeks for AV fistula infections, similar to treatment for subacute bacterial endocarditis 1
• Cannulation at the inflamed site must cease immediately, and the arm should be rested 1

Management of Inflammation Without Infection

• Rest the fistula until swelling is completely resolved 1
• Elevate the affected arm as much as possible to reduce swelling 1
• Apply ice to the inflamed area to help decrease pain and reduce the size of any infiltration 1
• If infiltration occurred after heparin administration, take special care to properly clot the needle tract without clotting the fistula 1

Imaging Evaluation

• If swelling persists beyond 2 weeks, obtain imaging to evaluate for potential underlying causes 1, 2
• Fluoroscopy fistulography is usually appropriate as the initial imaging study for suspected dysfunction of hemodialysis access 1
• Duplex ultrasound is an acceptable alternative for initial evaluation 1, 2

Specific Management Based on Underlying Cause

For Infiltration/Hematoma:

• If the fistula is infiltrated, rest it for at least one treatment 1
• If dialysis cannot be postponed, cannulate above the site of infiltration 1
• If the patient still has a catheter in place, restart use of the fistula gradually - beginning with one needle and advancing to two needles as the access allows 1

For Venous Stenosis:

• If imaging reveals stenosis >50% with associated clinical abnormalities, proceed with percutaneous transluminal angioplasty (PTA) 3
• High-pressure balloons (25-30 atmospheres) may be needed for resistant venous stenosis 1

For Infection at AV Anastomosis:

• Rare but potentially lethal - requires immediate surgical intervention 1
• Infected tissue must be resected; if arterial segment is involved, interposition graft using a vein or creation of a more proximal AV anastomosis may be needed 1

Prevention of Future Complications

• Ensure proper needle removal technique to prevent post-dialysis infiltrations 1
• Apply gauze dressing over needle site without pressure before removal 1
• Remove needle at approximately the same angle as insertion 1
• Do not apply pressure to puncture site until needle is completely removed 1
• Implement regular monitoring of access characteristics (pulsatility, thrill, flow, pressure) 1

Common Pitfalls to Avoid

• Attempting to cannulate through or near inflamed sites can exacerbate complications 3
• Delaying evaluation of persistent swelling can lead to access failure 3, 2
• Failing to recognize early signs of infection can lead to delayed intervention and worse outcomes 3
• Improper needle removal technique (using too steep an angle) can cause the needle's cutting edge to puncture the vein wall 1

Follow-up Care

• Regular monitoring should continue after resolution to detect any recurrence 2
• Evaluate for adequate blood flow before each subsequent dialysis treatment 1
• Record and track access characteristics in the medical record to be available to all caregivers 1