Can a peripheral intravenous (IV) line be inserted on the same side as a failed arteriovenous (AV) fistula?

Peripheral IV Line Placement in the Arm with a Failed Fistula

Yes, a peripheral IV line can be inserted on the same side as a failed arteriovenous fistula, but only after the fistula has been definitively abandoned and is no longer being considered for salvage or revision. The key consideration is whether the fistula might still be salvageable or if future access creation is planned in that extremity.

Primary Considerations

When Peripheral IV Access is Acceptable

• If the fistula is permanently failed and abandoned, peripheral IV access on that side becomes permissible since vein preservation is no longer relevant for that specific access 1
• After all salvage attempts have been exhausted and a new access plan has been established for the contralateral arm or alternative site 1, 2
• When urgent temporary access is needed and the ipsilateral arm is the only viable option for peripheral access, though this should be rare 1

When to Absolutely Avoid the Ipsilateral Arm

• If the fistula is undergoing evaluation for salvage: Early fistula failures can be successfully salvaged in 92% of cases when correctable pathology is identified, with 68% remaining functional at 12 months 3
• If revision or maturation procedures are planned: The failed fistula may still be salvageable through interventions such as angioplasty for stenosis or accessory vein obliteration 3
• If future access creation is anticipated in that extremity: Venipuncture complications can render veins unsuitable for future arteriovenous access construction 1

Guideline-Based Approach

Vein Preservation Principles

The KDOQI guidelines emphasize aggressive vein preservation strategies 1:

• All patients with kidney failure should avoid venipuncture and IV catheters in arms to preserve veins for potential access sites 1
• Subclavian vein catheterization must be avoided due to risk of central venous stenosis that would preclude use of the entire ipsilateral arm 1
• Medic Alert bracelets should be worn to inform healthcare staff about vein preservation needs 1

Access Planning Strategy

When a fistula fails, the recommended approach prioritizes 1, 2:

1. Place a tunneled dialysis catheter in the contralateral internal jugular vein to preserve the side with the failed fistula for potential future access 1
2. Evaluate the failed fistula for salvage potential through imaging (ultrasound or fistulography) to identify correctable lesions 1, 3
3. Plan the next permanent access based on the patient's individualized ESKD Life-Plan, considering remaining vascular options 1, 2

Critical Pitfalls to Avoid

Common Mistakes

• Prematurely abandoning early fistula failures: 78% of early failures have venous stenosis that is correctable, and 92% can be salvaged with aggressive intervention 3
• Using the ipsilateral arm for routine blood draws or IV access before confirming the fistula is permanently non-salvageable 1
• Placing peripheral IVs without considering the access plan: This can compromise veins needed for future access creation in that extremity 1

Special Circumstances

• If central venous stenosis exists on one side, that side should be used for catheter placement to preserve the contralateral side for future arteriovenous access 1
• Right-sided access is generally preferred over left due to more direct venous anatomy, unless pathology dictates otherwise 1

Practical Clinical Algorithm

Step 1: Determine if the fistula is truly failed or potentially salvageable

• Obtain imaging (duplex ultrasound or fistulography) to assess for correctable lesions 1, 3
• Consult vascular access team about salvage potential 3

Step 2: If salvage is not possible, establish the future access plan

• Identify which extremity will be used for the next permanent access 1, 2
• Place tunneled catheter in the opposite extremity if possible 1

Step 3: Only after confirming the failed fistula arm will not be used for future access

• Peripheral IV placement becomes acceptable on that side 1
• Continue to avoid the arm designated for future access creation 1

Step 4: If both arms have failed accesses and no upper extremity options remain

• Consider lower extremity fistula creation before resorting to long-term catheter dependence 1, 2
• Peripheral IV access restrictions become less critical once all upper extremity access options are exhausted 1