Learn about the different types of access types.
Left Arm Graft
The left arm graft is the last dialysis option in the arm, bridging the brachial artery just above the elbow and the brachial or axillary veins in the upper arm or axilla (arm pit). Flows tend to be good, since the blood vessels in the upper arm tend to be bigger. The graft usually sits under the shirt sleeve, making it more cosmetic.
Left Arm Loop Graft
The arm loop graft is placed when the forearm and upper arm fistula options are gone, and when the brachial artery near the elbow is too small. This option is frequently chosen in the fifteen to eighteen percent of patients who have “high-bifurcation”, a situation where the brachial artery divides into two smaller arteries in the upper arm instead of below the elbow as usual. Unlike the standard arm graft, the blood flow is from top to bottom in the front of the arm, and sometimes the dialysis staff will “run the patient backward”, leading to inefficient dialysis.
Left Arm Transposed Basilic AV Fistula
One StageThe basilic vein is the biggest vein in the arm, but it is too deep and in the wrong place to use unless we are willing to make three small incisions, free up the vein from its deep location, and move it closer to the skin. The “transposed” (moved) basilic AV fistula sometimes can be used within weeks, as it may not need much “growth” time. It is usually the last fistula option in the arm.
Left Brachiocephalic Fistula
The brachiocephalic fistula is the first choice for an upper arm access. The vein tends to be straight, close to the surface, and large. Maturation time can be as little as two months. Frequently when a forearm graft fails, the cephalic vein can be connected to the artery and used right away, already enlarged and toughened up by the outflow from the graft.
Left Forearm Loop Graft
The forearm loop graft is frequently chosen when there is no forearm fistula option, and when a fistula in the upper arm is not expected to mature quickly. The forearm loop can be used within weeks, and because it drains to the cephalic and basilic veins in the upper arm (which then grow) it can lead to an upper arm fistula in the future. The forearm loop ordinarily should not be done where there are suitable vessels for a forearm fistula.
The straight forearm graft is an option when the radial artery at the wrist is strong, but the cephalic vein in the forearm is either small or obliterated by IVs, and where an upper arm fistula option is not expected to mature quickly. If done appropriately, the veins in the upper arm will be built up by the forearm graft, and be usable for upper arm fistulas when the forearm graft fails. The forearm graft ordinarily should not be done where a reasonable forearm fistula option exists.
The wrist or forearm fistula is the first choice of fistulas where it is possible. It gives the longest length fistula, is the most convenient to use, and requires the least amount of surgery. This fistula keeps all the other options open. Even if the fistula never becomes usable, it will start building up the veins in that arm, making a fistula in the upper arm easier. Unfortunately, this fistula is not always possible: the veins may have been ruined by intravenous catheters, or the vessels may just be too small.
