What are the contraindications for Hemodialysis (HD) access?

Contraindications for Hemodialysis Access

Hemodialysis access has very few absolute contraindications, but several relative contraindications exist that require careful assessment and may favor alternative modalities or specific access strategies. 1

Absolute Contraindications

There are essentially no absolute contraindications to hemodialysis access itself, as some form of vascular access can nearly always be established. However, the following represent situations where specific access types are absolutely contraindicated:

• Lack of any viable vascular access sites (all upper and lower extremity vessels exhausted, central veins occluded) - this would necessitate consideration of peritoneal dialysis or conservative management 1
• Active systemic infection with bacteremia - temporary contraindication until infection controlled, particularly for permanent access creation 1

Relative Contraindications and Special Considerations

Central Venous Catheter (CVC) Site-Specific Contraindications

Femoral vein CVC placement is contraindicated in the following circumstances 1:

• Femoral or iliac vessel pathology or prior surgery/reconstruction
• Chronic unresolved diarrhea (hygienic concerns)
• Morbid obesity (BMI >35 kg/m²)
• Anticipated kidney transplant (preserves iliac vessels)

Subclavian vein catheterization should be avoided when future arteriovenous fistula (AVF) or graft (AVG) is planned, as it carries high risk of central venous stenosis that can preclude permanent access creation 1

Patient-Specific Factors Affecting Access Type Selection

Severe cardiovascular disease may influence access selection 1:

• High-output heart failure may contraindicate high-flow AVF creation
• Severe peripheral vascular disease may limit distal access options
• These patients may require lower-flow access or catheter-based approaches

Limited life expectancy or severe comorbidities make long-term catheter use more acceptable despite higher complication rates 1:

• Very elderly patients with multiple comorbidities
• Patients with severe congestive heart failure
• Those with extensive peripheral vascular disease
• Patients with anticipated survival <1 year

Anatomic limitations that preclude specific access types 1:

• Inadequate vessel size or quality (veins <2-3mm diameter)
• Prior central venous stenosis limiting ipsilateral access
• Extensive prior surgeries or trauma to potential access sites

Timing Contraindications

Non-cuffed catheters should not be used beyond 5-7 days due to exponentially increasing infection risk 1:

• Infection rates increase more than 5-fold compared to tunneled cuffed catheters after 2 weeks
• Patients should not be discharged home with non-cuffed catheters due to safety concerns

Premature cannulation of immature AVF increases failure risk and should be avoided 1:

• AVF typically requires 1-6 months maturation before use
• Early cannulation can cause hematoma, thrombosis, and access loss

Clinical Decision Algorithm

Step 1: Assess Urgency and Life-Plan

• Urgent dialysis need (<1 week): Tunneled cuffed catheter in internal jugular vein (right preferred), avoiding subclavian 1
• Anticipated long-term HD (>1 year): Plan for permanent AVF or AVG 1
• Short-term need (<3 months) with transplant planned: Femoral catheter acceptable to preserve upper extremity vessels 1

Step 2: Evaluate Vascular Anatomy

• Adequate forearm vessels: Radiocephalic AVF (distal first approach) 1
• Inadequate forearm, adequate upper arm: Brachiocephalic or brachiobasilic AVF 1
• No suitable veins, adequate arteries: Consider AVG 1
• Upper extremity exhausted: Lower extremity AVF/AVG or long-term catheter 1

Step 3: Consider Comorbidities

• Severe heart failure or high cardiac output concerns: Avoid high-flow AVF, consider lower-flow access or catheter 1
• Morbid obesity (BMI >35): Avoid femoral catheter; internal jugular preferred 1
• Active infection: Delay permanent access creation; use temporary catheter 1
• Anticipated transplant within months: Preserve vessels; use catheter if needed 1

Common Pitfalls to Avoid

Using subclavian catheters when permanent access is planned - this causes central stenosis in up to 50% of cases and can eliminate future ipsilateral AVF/AVG options 1

Discharging patients with non-cuffed catheters - infection risk, hemorrhage risk, and patient safety mandate inpatient status or conversion to tunneled catheter 1

Creating high-flow AVF in patients with borderline cardiac function - can precipitate high-output heart failure requiring access revision or ligation 1

Ignoring the "distal first" principle - starting proximally eliminates future distal access options when the proximal access fails 1

Prolonged catheter use (>3 months) without addressing permanent access - associated with 2-fold increased mortality risk and significantly higher infection and hospitalization rates 1, 2