Diabetes - The leading cause of kidney disease. To learn more, click here to watch the banner video on YouTube and here, to learn about the Singapore Ministry of Health “War on Diabetes”.

Dialysis Access: Arteriovenous Fistulae, Catheters and Complex Access Surgery in Singapore

Diabetes – The leading cause of kidney disease

To learn more, click here to watch the banner video on YouTube, and here to read about the Singapore Ministry of Health’s War on Diabetes.

Background

Whilst diabetes is the leading cause of kidney failure, sadly, the kidneys can fail for a number of reasons. When they do fail, the body is no longer able to remove toxins in the urine or manage the delicate balance of water and salts. This can be life-threatening.

In conjunction with nephrology colleagues, once the decision to start haemodialysis (artificial blood filtering via a dialysis machine) has been made, ‘access’ into the blood stream is required so that blood can be removed, filtered and cleaned, and then returned to the body.

Catheters

These are essentially large plastic tubes that are placed directly into the bloodstream. They can be temporary or permanent. Overall, they are not recommended for long-term use as the risk of bloodstream infections is much higher, but they serve an important purpose as a bridging measure until more definitive access can be achieved.

In some patients who cannot have a fistula or a graft created, catheters may be the only option. With meticulous care and maintenance, they can provide life-saving access for prolonged periods.

Arteriovenous Fistulae (AVF)

A fistula is a surgically created connection between an artery (carrying blood pumped away from the heart under pressure) and a vein (carrying blood back to the heart). This increases blood flow in the vein, allowing it to enlarge and strengthen over time.

When mature, the fistula provides reliable access for haemodialysis, with two needles inserted at each session so that blood can be removed, filtered, and then returned to the body.

International guidelines recommend fistulae as the gold standard for dialysis access because they last longest, have the lowest infection risk, and generally provide the best outcomes. Whenever possible, fistulae are created in the non-dominant arm and as close to the hand as feasible, to preserve other sites for future use.

Arteriovenous Grafts (AVG)

In cases where veins are too small or unsuitable for a fistula, a synthetic tube (graft) can be used to connect an artery and a vein. Grafts can often be used sooner than fistulae, but have a higher risk of infection and clotting.

Complex Access

Not all patients have suitable vessels for simple fistula or graft creation. In these cases, more advanced or “complex” access procedures may be required, sometimes involving upper arm, chest wall, or hybrid surgical-endovascular techniques. These procedures are tailored to each patient and are designed to preserve options for the future while maintaining reliable dialysis.

Summary

Dialysis access is a lifeline for patients with kidney failure. While catheters can be useful as a temporary or last-resort measure, arteriovenous fistulae remain the preferred option whenever possible. Grafts and complex access procedures also play an important role in ensuring every patient has a safe, reliable way to receive life-saving haemodialysis.

As a vascular and endovascular surgeon in Singapore, I work closely with nephrology colleagues to create and maintain dialysis access using the latest surgical and minimally invasive techniques.

Frequently Asked Questions (FAQ) about Dialysis Access

Why is dialysis access needed?

Dialysis requires rapid removal and return of blood to a machine. Specialised access ensures this can be done safely, reliably and repeatedly.

What is the best type of dialysis access?

An arteriovenous fistula is generally the gold standard. It lasts longest, has the lowest infection risk, and provides the best dialysis efficiency.

Why not just use a catheter long-term?

While catheters are simple and immediately usable, they have much higher risks of infection, clotting, and vein damage. They are best avoided long-term if other options are available.

How long does a fistula take to mature?

Most fistulae take 6–12 weeks to mature, though this varies. Some may require additional procedures to help them develop properly.

What if my veins are too small for a fistula?

If veins are unsuitable, a graft or complex access may be created. Your vascular surgeon will recommend the safest and most durable option.

Can a failing fistula or graft be salvaged?

Yes. Narrowings or clots can often be treated with balloon angioplasty, stenting, thrombectomy, or revision surgery to prolong access life.

How do I look after my dialysis access?

Keep the site clean, avoid blood pressure cuffs or blood draws on the access arm, and regularly check for the “buzz” (thrill) that indicates flow. Report swelling, redness, or absence of the thrill immediately.