What is the risk of infection when placing an intraosseous (IO) line on the same arm as an arteriovenous fistula (AVF)?

Intraosseous Access in the Same Arm as an Arteriovenous Fistula: Infection Risk and Contraindications

Placing an intraosseous (IO) line in the same arm as an arteriovenous fistula (AVF) is contraindicated and should be avoided entirely, as any invasive procedure in the ipsilateral arm poses significant risk of infection, thrombosis, and damage to the vascular access, which serves as the patient's "lifeline" for dialysis. 1

Primary Contraindication Based on Guidelines

The most recent and authoritative guidance comes from Diabetologia (2024), which explicitly states that placement of devices requiring insertion (such as CGM sensors, and by extension IO catheters) should be avoided in the ipsilateral arm when arteriovenous fistulas or grafts are present. 1 While this guideline specifically addresses continuous glucose monitors, the underlying principle applies universally to any invasive device placement.

• Blood draws, infusions, and any invasive procedures are contraindicated in the AVF/AVG arm due to the combined risks of infection, clotting, and damage to the arteriovenous access. 1
• The rationale is that the AVF represents the patient's critical dialysis access—their "lifeline"—and any compromise to this access can have catastrophic consequences for the patient's ability to receive life-sustaining dialysis. 1

Infection Risk Context for Vascular Access

While specific infection rates for IO placement in AVF arms are not documented in the literature (likely because this practice is contraindicated), we can contextualize the infection risk:

Baseline AVF Infection Rates

• Primary AVF infection rates should not exceed 1% over the use-life of the access. 1
• AVF infections are rare compared to grafts (which have 10% infection rates) and catheters (10% at 3 months, 50% at 1 year). 1

IO Catheter Complication Rates

• The overall complication rate for IO catheters across all sites is approximately 2.1%. 2
• Primary complications include extravasation, fractures, and osteomyelitis. 3
• No complications were identified in a large population-based study of 291 pediatric IO placements, though mortality was 37% in this critically ill population. 4

Critical Clinical Reasoning

The absence of specific data on IO placement in AVF arms reflects the fact that this practice is fundamentally contraindicated rather than simply high-risk. The reasoning is multifactorial:

1. Infection risk amplification: Any breach of skin integrity in the AVF arm introduces bacteria that could seed the high-flow vascular access, potentially causing access-threatening infection or systemic bacteremia. 1

2. Thrombosis risk: Trauma or inflammation from IO placement could trigger thrombotic complications in the already vulnerable AVF circulation. 1

3. Mechanical damage: IO needle insertion could directly damage superficial veins that are part of or feed into the AVF system. 1

4. Preservation principle: The entire ipsilateral extremity must be protected to preserve future access options, as patients may require multiple access revisions over their lifetime. 1

Alternative Access Sites

When IO access is needed in a patient with an AVF, placement should occur in:

• The contralateral arm (if no AVF present)
• The sternum (using FAST1 device) 3
• The lower extremities (proximal or distal tibia) 3

Special Considerations for Renal Failure Patients

Patients with advanced chronic kidney disease and AVFs have additional considerations that make ipsilateral IO placement even more problematic:

• Higher rates of coagulopathy and bleeding due to uremic platelet dysfunction may impact device functioning and increase bleeding complications. 1
• These patients are already at increased infection risk due to immunosuppression and frequent vascular access. 5
• PICCs and other upper extremity venous access devices are not advisable in patients with renal failure and impending dialysis need, as preservation of upper-extremity veins is essential for future fistula or graft placement. 1

Practical Implementation

In emergency situations requiring vascular access in a patient with an AVF:

1. Identify the AVF arm immediately upon patient contact
2. Mark or flag the AVF arm to prevent inadvertent procedures
3. Select alternative IO sites (contralateral limb, sternum, or lower extremity)
4. If temporary dialysis access is needed, place a tunneled catheter in a central location rather than compromising the AVF arm 1

Common Pitfalls to Avoid

• Never assume that "just one procedure" in the AVF arm will be acceptable—the cumulative risk and the principle of access preservation are absolute. 1
• Do not place IO access in the AVF arm even if the fistula appears non-functional or immature, as this may compromise future maturation or revision options. 1
• Avoid the misconception that IO access is "safer" than IV access in the AVF arm—both are contraindicated. 1