Make a Plan: Fistula, Graft and PD Catheter Placements

Depending on which form of dialysis you choose, you will have to undergo either peritoneal dialysis catheter placement or vascular access surgery. If you choose to do peritoneal dialysis (PD),  you will need to have a PD catheter placed in your lower abdomen. To perform PD, a special solution is instilled through your catheter. After a certain amount of time,  the solution is drained from your body through the catheter. This process is called an exchange and it cleans your blood. If you choose to do home hemodialysis (HHD), in-center hemodialysis, in-center nocturnal hemodialysis or in-center self care hemodilaysis, you will need to have a vascular access — either an arteriovenous (AV) fistula or an arteriovenous (AV) graft — created in your arm or leg to allow your blood to flow from your body through the dialysis machine to be cleaned, and back into your body.

Before making a decision about the type of dialysis you will do, it is important that you become knowledgeable about your choices. You should speak with your nephrologist, and it can also be helpful to meet with a dialysis educator, read and watch educational materials and even visit a dialysis center. Although some patients change the type of dialysis they do over time, this initial choice is an important one. It is best when this decision is made well in advance of needing to start dialysis, since PD catheter placement and vascular access surgery both require proper planning.

Peritoneal dialysis (PD) catheter placement

If PD seems like a good option, your doctor will examine you and check for any problems you may have with your abdomen, such as hernias or muscle weakness in the walls of your stomach. If your doctor determines that you are a good candidate for a PD catheter, then you will be scheduled for catheter placement surgery.

Prior to this operation, it is important that you meet with your PD nurse to plan your catheter placement and arrange for follow-up. Your PD nurse will meet with you and tell you exactly what to expect. You will receive clear instructions about what to do both before and after surgery. In most cases, you will be asked to return and visit the nurse a few days after your operation.

PD catheter placement is usually done under general anesthesia, but most patients are able to go home the day of the procedure.

A peritoneal dialysis (PD) catheter is a soft, flexible plastic tube about the length of a ruler and the width of a pencil. During surgery, one end of the catheter will be put into your peritoneal cavity. The rest of the catheter will come through your lower abdomen, underneath and to the side of your belly button. This tiny hole, where the catheter comes out of your body, is called the exit site.

There are two common ways of placing a catheter: laparoscopic and surgical.

  1. Laparoscopic
    Laparoscopic PD catheter placement is the most commonly used technique. It uses general anesthesia and requires that two small incisions be made in the abdomen. The first is for the laparoscope, which allows the surgeon to see inside the peritoneal cavity. The second is for the catheter itself, which is tunneled through the abdominal wall and out the exit site for use once dialysis is started.
  2. Surgical
    Surgical catheter placement is another commonly used technique. The patient is given general anesthesia. The surgeon makes an incision through the abdominal wall into the peritoneum and then places the catheter through that incision into the proper position. The catheter is then tunneled through the abdominal wall until it exits in the appropriate location.

A transfer set will be placed onto your catheter by the surgeon during surgery. A transfer set is a 4- to 6-inch piece of tube with a valve on the end that is used to open and close your catheter during the exchange process. A transfer set can be put on after surgery in a dialysis center, but to avoid infection, it is best to have it put on during your PD catheter placement operation.

After surgery, your doctor or nurse will monitor your blood pressure and pulse and check your exit site. You may be allowed to go home the same day, although some patients will be kept overnight after the operation. You may have some mild abdominal discomfort and should be given pain pills in case you need them. You will be sent home with bandages over your catheter exit site, and it is important that this be kept dry. You should visit your PD nurse or surgeon within the next few days to have the site inspected, and you should not change the dressing yourself without permission. The nurse will make certain that you are doing well and that there are no problems with the catheter. It should be reassuring to you to know that a nurse will now always be available to help as you begin treatment with peritoneal dialysis.

Most patients will wait at least two weeks after surgery to begin PD training. However, exceptions may occur when there is a need to start PD sooner. Your nephrologist will be the one who makes this decision and who oversees the nurses who provide your PD training.

Fistula placement for hemodialysis

An arteriovenous (AV) fistula is created by connecting one of your arteries to one of your veins using your own vessels. It is best if the decision to have the fistula surgery is made well before you need dialysis. This is because once the fistula is created, it takes approximately three to six months for the fistula to “mature” or become developed enough to use. Fistulas are the preferred type of vascular access for all hemodialysis patients. Doctors prefer fistulas because they provide good blood flow and generally last longer than other types of access. Because a fistula is created from your artery and vein, it is a natural part of your body. It usually takes between 4-16 weeks for a fistula to be ready to use, so it is often best to have the fistula placed well before you need to start dialysis.

Before your fistula surgery, you may undergo a test to determine whether your veins are large enough for a fistula. Once your doctor has decided you are a good candidate for a fistula, you will be scheduled for surgery. Fistula placement is generally performed as an outpatient operation. Your doctor will usually sedate you and numb the area where the fistula will go, but you may be put to sleep by an anesthesiologist.

Fistula surgery usually takes less than 90 minutes. During the operation, your surgeon will connect an artery and vein. First, your surgeon will create a small opening in the side of an artery. Then, he or she will divide the vein and sew it to the opening in the artery.

After surgery, your doctor may advise you to keep the fistula area elevated to reduce swelling. He or she may also prescribe pain medication. To strengthen your fistula, you can do exercises such as squeezing a rubber ball.

Graft placement for hemodialysis

If your veins are too small for a fistula or your veins are blocked, your doctor may suggest an arteriovenous (AV) graft. A graft is a man-made tube that is inserted into your arm to connect an artery to a vein.

Most graft operations take fewer than 90 minutes. During the surgery, your surgeon will sew one end of the graft to a vein. He will then sew the other end to an artery. He will either place the graft tubing in a straight line or curve it to form a loop.

Grafts can usually be used for dialysis within two to six weeks. However, your doctor may suggest waiting four to six weeks to ensure your graft is fully healed.


The type of access surgery you undergo depends on the home dialysis modality you and your doctor decide is right for you. Talk with your doctor today about the home dialysis options available to you, or call 1-800-244-0582 to speak with a DaVita Guest Services Specialist.

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