What does a Healthy Dialysis Fistula Look Like?

Mattie P saw the pic of my fistula and asked: Is your fistula considered healthy?

It is. However, you often can’t tell by looking. There are several ways to tell:

  • It has a strong ‘thrill” (a whooshing noise and a buzz in time with your heart beat, where the vein is joined to the artery). This indicates lots of blood flow, which is what is needed if the arterial needle is to get enough blood to push through the machine.
  • If you keep your arm straight and raise your hand above your head, the blood should drain from your fistula, and leave it looking like a deflated balloon (see video below). This is also good, because it shows that your fistula is not clotted or blocked and that the blood is coming from and going to the rest of your body.

  • When you lower your arm, your fistula fills up again, quick smart. Good for the same reason as above.
  • When you gently press on the fistula, it is painless, soft and resilient, again indicating good blood flow.

Eventually, your fistula will get hardy and tough (and ugly, but that’s what shirt sleeves are for). All things are relative. Young fistulas are soft and can be fragile. As they get used, the fistula (vein) wall gets covered in scar tissue, which acts to protect it a little from the constant needling. Hopefully, you experience fewer and fewer blow outs from over-enthusiastic needling or from an inadvertent arm fold or bend that blocks the return (venous) blood flow.

Two things you don’t need in your fistula: blockage or clotting and infection.

Blocking or clotting directly impairs the efficiency of the dialysis (since less blood is being cleaned) and thus seriously endangers your health. You can tell if there is a problem by looking for the above healthy symptoms: strong thrill, quick emptying and filling, soft and resilient (no unexplained lumps). If you have a problem, tell your primary nurse and or doctor ASAP. The usual remedy is to have a small operation to have the blockage cleared.

Infection is really bad news. The first signs of an infection may be redness, leakage, pain, skin wearing away resulting in exposure of the fistula wall or a combination. It does not impair the blood flow, but it can spread throughout the body and cause sepsis (a toxic condition resulting from the spread of bacteria from the fistula), and even death. Unless caught early, infection can certainly lead to a loss of the fistula. This means a Permacath and all the pleasures that come with it, a stay in hospital to treat the infection and to create another fistula or graft.

Infection is most common in new fistulas, for a couple of reasons: because you are new to the whole process and can make mistakes with infection control; and because you often spend more time in hospital, where infections are more common. Prevention is the key. Always wash your hands and fistula before start dialysis, always use alcohol or other antiseptic swabs before any needling. Wear a glove when you help to remove the needles at the end of the run. If you dialyse at a unit, follow scrupulously the unit’s infection control procedures.  If at home, set up and follow you own procedures.

Anna Catteral once said to me when I had just begun the BigD, and I will never forget it: “Your fistula is your lifeline, look after it.” It is, and I do.

Afternote: The arm lift test shows that the blood flow from the fistula to your body is in good condition.  It does not show how well blood is flowing into your arm, via the anastomosis (where the vein and the artery are joined).   See here for more info.

63 thoughts on “What does a Healthy Dialysis Fistula Look Like?”

  2. Pingback: Improving your Dialysis Efficiency « Big D and Me

  3. My son, Andy, has just now started regular dialysis treatments. He just had the fistula put in his arm. For now he receives treatments through port near his neck till his arm heals. He is 23, and received transplanted kidney in 2004. It has pretty much failed since a terrible bout of double pneumonia this past March. Hoping for another kidney at some point. Any advice will be greatly appreciated. From his mom, Lisa
    Thank you.

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    • Hi Lisa and Andy and welcome. Firstly, I’m sorry to hear that your transplant has failed Andy. The problem with having little or no immune system means that you catch any and everything, and the impact is more severe. This transplant caper is a rough ride. At least you are not alone. From what I can tell, there seem to be as many sad stories as good ones. Despite what the doctors say, transplantation is still an art rather than a science.

      With regard to the near future, just take each day as it comes. Get used to dialysis as part of your life, at least for the present. The permacath is a bit of a nuisance, but at least connecting up is simple and painless. Once your fistula heals and is ready for use, the dialysis will become routine, and your time between sessions will be a little more normal. Have a look at the Getting the Needles In posts for a little more about this.

      It will take about a week of dialysis to start to feel human again. Once that happens, I am sure you will both feel a little more positive about life and the future.

      Good luck and keep in touch.
      Greg

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      • Hello, my grandpa has one in his arm! He has been doing dialysis for about 6 years now. The ports have never been changed. He never had problems until now. They were full of blood clots and the doctors tried to clean them out but didn’t’t completely clean them out. That was Friday, it is now Tuesday and he is in the hospital due to a heart attack. I was wondering if they could be related?

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  5. My dad is 87, wears a pacemaker and has had a history of TIAs, remaining independent through it all. Now he is told he will eventually have to go on dialysis. What is the risk for someone his age, having heart attack, infection or a serious stroke while on dialysis?

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  9. My dad is 90 and having to start dialysis soon, he is having his fistula done in about 2 weeks. He still has a active life, bowling on a league once a week, gardening, outing with 4 childrens, lives alone. Us kids are worried that dialysis will change all this. He is wanting our opinion on weather he should have it done, we told him it has to be his decision.

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  10. Hi, It’s been three years since my transplant, and my fistula is going strong. My 2 yr old niece was amazed when she accidentally touched and I let her push on it a couple times, but it kinda hurt so I said thats enough. Problem is it looks like it’s bulging a bit in the area she pushed on. Do you think thats an issue?

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    • Hi Justine. A bulging fistula is pretty normal. They grow fairly steadily firstly because of the pressure from the artery and secondly from all the needling. Obviously if the bulge is large, or in one spot, it should be checked for strength. If it is a little sore, it may just be an after-effect from your last session. If is is quite sore or red and sensitive, again, get it checked. Your unit should have a specialist nurse to talk to about your fistula (and your dialysis generally). Failing this, make an appointment with your nephrologist. If you are worried, do it soon and keep asking until you get an answer. Keep in touch. Greg

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  11. My sister who is 55 years old is on dialysis for probably around 5 years, i think out of those years, she had 2 fistula put in because the other one failed, so right now on the new one and if i am right is more than a year old, her arm grows larger or swollen, perhaps you know the right term? But she said it does not hurt, it is enlarged. So what is the best thing to do? She had it scanned but it shows nothing. Will you pls help me answer this, because her doctors don’t explain it well, and now the doctor wanted another surgery to put a new fistula and of course a temporary vascular access. Pls explain and what to do?

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    • Hi Liza, thanks for the comment. Fistulas grow because they are constantly punctured, and the pressure from the artery is like a in balloon. If there is a slight weakness in the fistula wall (and each puncture creates a weakness, at least temporarily) you get a little growth in size. After a few years, the fistula can become quite large. However it is not dangerous unless something is causing a weak area, like an infection, or overuse in one area , where several punctures are close to each other. As we get older, our skin and the vessel walls get thinner naturally and we need more care after needle removal. However, 55 is not old.

      Without seeing the fistula, it is difficult to say why your sister’s doctor wants to create a new one. However the most common reasons for needing a new fistula are blockage, where there is not sufficient blood flow to dialyse properly, and weakness in the fistula wall, where there is a danger of the fistula rupturing. If you are doubtful about it, make an appointment and ask the doctor for a more detailed discussion.

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      • My dad is 72 he got his firstly a month ago but had to put tunes his neck to start dialysis but his arm has a big knot and hand is cold finger nail r blue sent him to er told us to see vascular doc on Tuesday should we be worried

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      • Hi Penny. Your Dad’s blue finger is possibly due to “Steal Syndrome”, which is where the fistula, especially if it is knotted or blocked, “steals” much of the blood supply that should flow to his hand. Seeing the vascular surgeon is exactly the right thing to do. If is is steal syndrome, the surgeon will certainly take action. All should be Ok. Let me know how it goes. Regards, Greg

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  12. Thanks for sharing this. I am in limbo where I need a transplant, and closing in on requiring dialysis. Watching this video made it a little less scary. Thank you.

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  15. My husband just had a fistula done 2 weeks ago,looks good. He is not on dislysis, but this was just in case he had to start. He had a double lung transplant 8 years ago and kidney are not doing good. As a rule how long does a dialysis session take……

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    • A typical regimen is 3 x Four hour sessions per week, though this depends on the person’s stature. Smaller people can get away with less, larger people often need more. Keep positive, all will be well. Greg

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  16. I started dialysis a month via permacath. My fistula was created 2 weeks ago so it will be a while before it can be used. I am considering the buttonhole technique. Can any renal nurse do this or does she need to specialise in it? I have not heard of this being done in Australia
    Anne

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    • Hi Anne. Buttonholing is becoming common in Australia, but it tends to be unit dependent. My unit, Diaverum in Greensborough recently had more people buttonholing than not. Nurses do need to be trained in to buttonhole and wherever possible it is best to have the same person put in the needles each time. However, in my unit multiple nurses work together and talk each other through each patient’s buttonhole and it seems to work well. You are right to consider buttonholing. It has many advantages. Make enquiries at the unit you intend to use, and ask around at others. Let us know how you go. Good luck! Greg

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  18. MARY ANN January 2013 I just had a Fistula done On Wednesday, I am not on Dialysis’ yet. I hate the scar that it made on my arm. I can deal with that, but I can’t deal with is the lumps bumps on see on other patients arms. Will I have them with Fistula or does that only happen with Dialysis? What will happen with Buttonholing?

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    • Hi Mary Ann. The bumps come with dialysis – a reaction to constant needling. Your new fistula will be quite subtle (except for the buzz) until needling begins. Buttonholing tends to slow the growth of the bumps.

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  19. Does everyone get large lumps? And will your arm ever look normal again?
    I’m facing dialysis and I’m pretty freaked out.
    Thanks for your time.

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    • The longer you have your fistula the more likely the lumps will stay. Your arm will probably never look normal again unless they remove the fistula/ graft which is rare. I had a graft placed in my left arm and thought they would remove it once it clotted but it was not and they will not remove it. Sorry

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  20. I just recently had my fistula put in 2 days ago and yesterday it started leaking bloody puss and I just want to know if this is normal because my surgery is still fresh or should I go back to the hospital and let the Dr. check it out.

    Thx 4 listening…Nicole

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  21. Hello! This is my 1st comment here so I just wanted to give a quick shout out
    and say I truly enjoy reading through your posts.
    Can you recommend any other blogs/websites/forums that
    deal with the same subjects? Thank you!

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  22. I’m getting my fistula this week. I’m pretty freaked out. I’m an entertainer and this is the most gross thing I can imagine for someone who needs to look good all the time. Plus my Dr. says I may lose some of the feeling in my hand which will put me out of work. How do you cope with this crappy thing?

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    • Hi Aunt Lindy. You needn’t worry too much. It is unusual to lose feeling in you hand overnight. Mine is now 17 years old, and the only feeling I have lost was due to Carpal Tunnel, which seems to be a long term problem for people on dialysis (by long term I mean 5-10 years). The same goes for the lumps. My friend Max has been on BigD for 8 years and his fistula is just becoming noticeable. The lumps tend to come if you use the rope ladder puncturing technique (where you use a new hole each session) like I did for the first few years. Greg

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  23. Hello, here is my dilemma. I’ve been dealing with kidney issues since I was age 9. I am 37 now and have had three transplants. I was on PD for the first part of my life and about 14 years ago had to return to dialysis and decided to go to Hemo and was given a graft which only lasted for 4 treatments before it clotted. I remained on dialysis with a catheter until I received my third transplant that lasted for 9 years. I’m back on dialysis and have two potential donors. I had the vein mapping done and was told that I have a good vein on my right arm for a fistula. My fear is that I get a transplant again and when this one fails in 10 – 15 years my arm may possibly clot and when I need to return to dialysis I will not have access in any of my arms. I have been on dialysis now for 3 years and the transplant team is working on my new transplant within the next few months, in the meantime i have been using my catheter. I take care of it and am aware of all the risks, however I feel that since I’m still quite young my heart can handle the catheter right now but will not in the future. What would you do?

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    • Hi Giovanna. You are certainly thinking ahead! For me, it would depend on how long I have to wait before my transplant. If the transplant is definitely going to happen within a few months, I would continue with the catheter. It\f it is uncertain or the wait is much longer, I would go for the fistula. Not all fistulas clot when not in use: I have had two transplants. One lasted a short time (3 months) the other for 3 years. In both cases my fistula continued to work as normal, with good blood flow.
      But clotting can happen. I have asked Chris, my very experienced Unit Manager about rescuing a clotted fistula. She says that there is no definitive answer; it depends on how long it has been clotted. If you can get to a hospital within 6 hours it may be able to de-clotted by an experienced radiologist. Alternatively a good vascular surgeon will unblock an access and fix the reason for the clotting, eg. a stenosis. Only if that fails will they look at making another access. Of course, you need to act quickly once you recognise there is a problem; time is of the essence.
      Good luck! Greg

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  24. My mother is 80 and freaking out over having dailysis in 8 weeks. Your website shows she is not alone. She has to have a second surgery to connect her fistula to a port? What is that?

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  26. Hello
    I do dialysis at home 5 day a week for four hours a time. I have a fistula on my left arm where I have been button holing for over 16 months. Over the past 2 months I have had trouble getting my needle in on my V sight. I have been telling the care team and they kept saying it was because it was dry. Due to my constant nagging I managed to get a scan done at the unit by a nurse and he told me that there were a couple of clots. I then went for a full scan where I have been told that I have to start two fresh sights as he is going to yet again balloon my fistula through my A to my V, as it is narrowing off. Due to button holing I use blunts as you know can you put a sharp needle back into the already formed button hole?? or is this dangerous.

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    • Hi Jonathan. Not a good idea to use a sharp on a buttonhole that uses blunts. I have done it (usually when I am hassled because I’m having trouble with the hole) and I end up having to start a new hole. I recently abandoned a V hole that was giving me trouble and started two new holes away from the previous ones and things are OK now. Certainly your fistulagram and angioplasty are important, but it would also be good to try some new spots away from that area. If you are not confident about starting new holes ask someone you trust to do it. Use the sharps for 4-6 runs, then go back to the blunts. Hopefully all will then get back to normal. Greg

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  27. Hi there,
    I have my Fistula for 31 years, got it at age 16. It was never clotted or infected and still works like at the first day. Of course there is an aneurysm at the surgery point and it has some loops, but its still in good shape.

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  28. Hello, I’ve been searching for information about renal failure. In the early 80’s a friend of mine suffered kidney failure. She had some kind of device implanted in her wrist. She said during the surgery they went through her groin area on both sides and she had me feel her wrist. I felt a vibration under her skin, then she put it to my ear and heard a humming noise. I’m wondering if it was a fistula. Her skin wasn’t raised like in the video you included. There was a small scar on her wrist that almost looked like a skin graph. Any information you could give me on the subject would be greatly appreciated.

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  29. I just had a fistula out in the 1st of Oct. My question is: is it supposed to burn like someone is holding a lighter below it??? My scar is from the elbow to the Arm pit. Thanks in advance!!!

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    • Hi Lois. No, whatever the case, it is not supposed to burn. It may have become infected. If I were you, I’d go back and get them to check it ASAP. Greg

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  30. My husband got his fistula done in April of 2014. He was scheduled to have the vein moved because the access would have been hard to get at. So the surgery was done in January of 2015. This was at the time he went on dialysis using the port in his chest. He got an infection in it and it had to be cleaned out. This was Feb. Of 2015. They started using the fistula in the beginning of April. It has been difficult to get in ever since.
    May 2, 2015 he had to go in and have the small part of the vein ballooned. The doctor marked the arm with a permanent marker where the needles would go in and told us not to wipe them off.
    Now the fistula is not working due to clots. Is it about time to get another doctor or is this normal?

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  31. I would like to thank you for the efforts you have put in writing this blog. I’m hoping the same high-grade blog post from you in the upcoming as well. Actually your creative writing abilities has encouraged me to get my own site now. Actually the blogging is spreading its wings fast. Your write up is a great example of it.

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  33. Hi. I just came across this site as I was looking for answers via Google. I was on dialysis for 3 years and have a fistula in my right arm – it is in the crook of my arm where my arm bends at the elbow. I have had my kidney transplant for 6.5 years now. I am deeply concerned about my fistula because although it has not been used in a long time now, it has gotten so big and grotesque since the day it was last used for dialysis. Is this normal? I have a strong “thrill” and my kidney doctors tell me that the fistula is fine but I am so worried because it is now hardened and so huge. It hurts to wear anything with sleeves. Could you please tell me if it is normal for it to get so big? Will it continue to get bigger? I am only 36 and don’t want it getting larger.

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    • Hi Traci. Fistulas grow at varying rates, but usually only gradually, and usually only while they are in use. I haven’t heard of one growing like yours, so many years after your transplant, but maybe the location in the crook of your elbow has something to do with it. If it is hard and hurts like you say, it may be clotted or blocked in some way and the blockage may be causing the swelling. Either way, I think there is something wrong. Make an appointment with a vascular surgeon, ideally the one who created the fistula and get some expert advice. Don’t let it go on. Good luck. Greg.

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      • Hello. Im Lynn from the Philippines. Im on a wheelchair since i was 4 years old cause of a car accident. And i have a newly operated fistula in the arm. Its 2 months old. Im scared that the thrill is very slow unlike before the 1st time its very strong. Sometimes when im taking a bath or elevating it over my head the thrill will disappear. But when i put it back down it comes back again. Can you tell me if its normal that i cant feel the thrill? And very low? Thank you.

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      • Hi Lynn. Sorry for the slow reply, but I am in hospital at the moment and I expect to be discharged in a couple of days. I have asked around about your question and I will get back to you shortly.

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      • Hi again LynnGene. Sorry for the slow reply. I asked around and one of our local nephrologists wrote a brief response that may be helpful:

        “It is normal for the vein to collapse when the arm is lifted above the heart.
        If there is a reduced “thrill” there could be an inflow issue. Vascular surgery review recommended.”

        All I can say is that if I raise my arm over my head, my thrill becomes very hard to find too. That makes sense, because the blood flow drops to a trickle when you lift your arm, so with minimal blood flow you would have minimal thrill. Also, the thrill is caused by your blood flow, so it is always the same speed as your heartbeat. So if you have a slow heartbeat, you will have a slow thrill, and vice-versa. If you are worried, by all means ask your doctor, but from what you say, I think it sounds pretty normal. Regards, Greg

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  34. hey i got a question my upper arm fistula is hard so when i put my arm up it should look like a deflated balloon but it doesn’t look like that n i don’t feel the vibration i just feel the pluse what does that mean please help

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  36. Very good explanation exactly what I was told and live by. If you feel that it looks unsightly you could also wear a length of tubular grip or cut a sleave off of a jumper. Try to avoid flattening the swelling.

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