AV Graft Placement

Introduction

If you have kidney failure and need hemodialysis, your blood must be able to leave your body, pass through the dialysis machine, and return several times a session. To make this possible, you need a reliable point of access to your bloodstream. An AV graft is one of the main ways doctors create this access.

AV graft placement is a surgery in which a soft synthetic tube is placed under the skin of your arm (or sometimes your leg or chest) to connect an artery to a vein. Once it has healed, the graft can be used for dialysis sessions, usually three times a week, for years.

This article is written for people who have been told they may need an AV graft, who are preparing for the surgery, or who have already had one placed and want to understand what comes next. It explains what the graft is, when doctors choose it, how it compares to other access options, what happens during and after surgery, and how to look after the access so it keeps working as long as possible.

What Is an AV Graft?

AV stands for “arteriovenous,” meaning between an artery and a vein. An AV graft (sometimes called an arteriovenous graft) is a short length of soft, flexible synthetic tube placed under the skin to join an artery directly to a vein. The most common material used is expanded polytetrafluoroethylene (ePTFE), a smooth, biocompatible plastic. Some newer grafts use other biological or hybrid materials.

The purpose of the graft is to create a section of blood vessel that is large enough, strong enough, and close enough to the surface of the skin to be punctured with dialysis needles three times a week, year after year. Normal veins are too small and too fragile to be used this way. By connecting an artery (high pressure, fast flow) to a vein through the graft, blood flow through that section becomes high enough to support the dialysis machine.

During a dialysis session, two needles are placed into the graft — one to draw blood out to the machine, one to return cleaned blood to the body. Between sessions, you live normally with the graft sitting under your skin.

A working AV graft is one of three main forms of long-term hemodialysis access:

• AV fistula — a direct surgical connection between your own artery and vein, with no synthetic material
• AV graft — an artery-to-vein connection made through a synthetic tube
• Central venous catheter — a tube placed into a large vein in the neck, chest, or groin, used for short-term or bridging access

Why Is an AV Graft Placed?

AV graft placement is performed for one main reason: to create durable vascular access for long-term hemodialysis in someone with end-stage kidney disease (also called kidney failure or ESRD).

Major kidney care guidelines, including those from the Kidney Disease Outcomes Quality Initiative (KDOQI) and the European Society for Vascular Surgery (ESVS), generally describe an AV fistula as the preferred first-choice access where it is feasible. However, a fistula is not possible or not the best option for every patient. An AV graft is often chosen when:

• The patient’s own veins are too small, too damaged, or too scarred to form a usable fistula
• A previous fistula has failed
• Dialysis is needed sooner than a fistula could mature (a fistula usually needs two to four months to mature; a graft can often be used within two to four weeks)
• The patient has a body habitus or vascular anatomy that makes a fistula unlikely to develop reliable flow
• Previous central venous catheters have caused damage to the veins in the chest, making fistula maturation unlikely

The decision between a fistula and a graft is increasingly made on a patient-by-patient basis, with current guidelines favouring the access that is most likely to work well for the specific person rather than a one-size-fits-all preference.

Who Is a Candidate?

An AV graft may be considered for someone who needs ongoing hemodialysis and whose vascular anatomy or clinical situation makes a fistula less suitable.

Before placement, a vascular surgeon will usually perform:

• Physical examination of both arms, including pulses, scars from previous IV lines or surgery, and visible veins
• Vascular mapping with ultrasound to measure the size, depth, and quality of arteries and veins in the arms (and sometimes other sites)
• Review of medical history, especially previous catheters, fistulas, central line placements, pacemaker leads, and any conditions affecting the heart or blood vessels

Factors that may push a decision toward a graft rather than a fistula include very small veins, heavy vein scarring, urgent dialysis need, advanced age combined with poor vessel quality, or repeated failure of attempts at fistula creation.

Factors that may make any forearm or upper-arm access difficult include severe peripheral vascular disease, central vein blockages, severe heart failure that would not tolerate the extra blood flow through the access, and active infection at planned puncture sites. In these situations, the surgeon may consider less common graft locations (such as the thigh or chest) or alternative dialysis methods.

AV grafts are mostly placed in adults. Children needing dialysis may also receive grafts, but pediatric vascular access decisions are made by specialised teams and are often influenced by the child’s size, expected time on dialysis, and likelihood of kidney transplant.

Alternatives to AV Graft Placement

An AV graft is one of several ways to access the bloodstream for kidney replacement therapy. Understanding the main alternatives helps in the conversation with your nephrologist and vascular surgeon.

AV Fistula

An AV fistula is created by surgically joining one of your own arteries directly to one of your own veins, usually in the wrist or upper arm. Over weeks to months, the vein enlarges and thickens (“matures”) to handle high blood flow and repeated needle punctures.

Major guidelines, including KDOQI, generally describe AV fistulas as having the lowest rate of infection and the longest functional lifespan once they mature. The trade-offs are that not every patient has veins suitable for a fistula, maturation takes time, and some fistulas fail to mature even when planned carefully.

Central Venous Catheter (Dialysis Catheter)

A central venous catheter is a flexible tube inserted into a large vein, usually in the neck (internal jugular vein) and tunnelled under the skin to exit on the upper chest. Two channels in the catheter allow blood to leave and return during dialysis.

Catheters can be used immediately, which is why they are common when dialysis must start urgently. However, current guidelines describe long-term catheter use as carrying higher rates of infection (including bloodstream infection), clotting, and damage to the central veins. They are generally considered a bridging option while a permanent access matures, or a last resort when no other access is possible.

Peritoneal Dialysis

Peritoneal dialysis uses the lining of your abdomen, called the peritoneum, as the filtering membrane. A soft tube called a PD catheter is placed surgically into the abdomen. Dialysis fluid is run in and out through this tube, drawing waste products out of the bloodstream across the peritoneal lining.

Peritoneal dialysis is done at home, often overnight, and does not require any vascular access. It is an alternative for many people, though it is not suitable for everyone — previous abdominal surgery, certain medical conditions, and home circumstances all affect whether it is a workable option.

Kidney Transplant

A kidney transplant is the definitive treatment for end-stage kidney disease for those who are medically suitable. A transplant removes the need for ongoing dialysis. Many patients on dialysis are also on a transplant evaluation pathway; the access placed for dialysis is intended to support them until a transplant is possible (or for the long term if it is not).

Several variations exist in how an AV graft is designed, where it is placed, and which material is used.

Graft Material

Most AV grafts are made from ePTFE (expanded polytetrafluoroethylene), a soft synthetic material that is well tolerated by the body and has a long track record. Newer biosynthetic and biologic grafts are available in some centres and may have different healing or patency profiles, but ePTFE remains the most widely used.

Graft Configuration

A graft can be placed in different shapes depending on the anatomy:

• Straight graft — runs in a relatively direct line between artery and vein, often in the forearm or thigh
• Loop graft — forms a U-shape under the skin so that a longer length is available for needle puncture; common in the forearm
• Curved or angled grafts — used where anatomy makes a simple straight or loop configuration difficult

Graft Location

The most common locations, in approximate order of preference, are:

• Forearm graft — typically connecting the brachial artery at the elbow to a vein in the forearm, often as a loop
• Upper arm graft — connecting the brachial artery to the axillary or basilic vein in the upper arm
• Thigh graft — used when arm options have been exhausted; placed between vessels in the upper leg
• Chest wall or “necklace” graft — used in highly complex cases where most other access sites have failed

Doctors typically try to preserve the non-dominant arm for access where possible and start as far from the heart (distally) as anatomy allows, so that more proximal sites are kept in reserve for the future.

Preparing for AV Graft Placement

Preparation for an AV graft involves both medical and practical steps.

Pre-operative Assessment

• Vascular mapping ultrasound to choose the artery and vein
• Blood tests including a full blood count, kidney function, electrolytes, and clotting
• Cardiac assessment in patients with significant heart disease, since the new access adds blood flow load on the heart
• Review of medications, especially blood thinners, antiplatelet drugs, and diabetes medications
• Skin check at the planned surgical site for any infection, rash, or wounds

Things to Tell Your Surgical Team

• All medications, including over-the-counter drugs and herbal supplements
• Allergies, especially to medications, latex, or local anaesthetic
• Previous central lines, dialysis catheters, pacemaker or defibrillator leads, and previous fistula or graft attempts
• Bleeding or clotting conditions in you or in your family
• Pregnancy, if relevant

Protecting the Access Arm Before Surgery

Once an arm has been chosen for the access, doctors typically advise that no needles, IV lines, or blood pressure cuffs be used on that arm. This protects the veins from damage before they are needed. Patients are often given a wristband or asked to remind staff.

Day of Surgery

• You will usually be asked not to eat or drink for several hours before surgery
• Some medications may be paused, others continued — follow the team’s specific instructions
• Wear loose clothing that does not need to slide over the operated arm afterwards
• Arrange someone to take you home if you are having day-case surgery

What Happens During AV Graft Placement

AV graft placement is usually performed in an operating room or specialised vascular procedure suite. The operation typically takes one to two hours.

Anaesthesia

The surgery can be done under:

• Regional anaesthesia (a nerve block) that numbs the whole arm
• Local anaesthesia with sedation
• General anaesthesia, in some cases

The anaesthetist will choose based on your overall health, the complexity of the operation, and your preferences.

The Operation

The surgeon makes two small incisions over the chosen artery and vein. A tunnel is created under the skin between them, and the synthetic graft is passed through this tunnel into position. One end of the graft is sewn to the artery, the other to the vein, using very fine sutures. Before closing the incisions, the surgeon confirms that blood is flowing through the graft. A vibrating sensation (called a “thrill”) and a whooshing sound (a “bruit”) over the graft confirm good flow.

The skin incisions are closed, usually with absorbable stitches under the skin and dressings on top.

Immediately After

You will be observed in a recovery area for a few hours. The surgical team checks:

• That the graft is still flowing well
• That circulation in the hand or foot beyond the graft is normal
• That there is no excessive bleeding or swelling

Many patients go home the same day or the next day, depending on the centre and individual circumstances.

Recovery and Healing

Recovery after AV graft placement happens in two overlapping stages: healing of the surgical wounds, and incorporation of the graft so that it can safely be used for dialysis.

The First Week

• Some bruising, swelling, and discomfort at the incision sites is normal
• The arm may feel tight or heavy for several days
• Keep the dressings clean and dry as instructed
• You will be shown how to feel for the thrill (the vibrating sensation) over the graft — checking this once or twice a day helps catch problems early
• Avoid heavy lifting, pressure on the arm, and sleeping on the arm

Pain and Swelling

Most people manage discomfort with simple painkillers as advised by their team. Severe pain, increasing swelling, redness spreading from the wound, fever, or coldness and numbness in the hand should be reported promptly.

When the Graft Can Be Used

A key advantage of AV grafts compared to fistulas is that they can usually be used for dialysis sooner. Traditional ePTFE grafts are typically ready for use about two to four weeks after surgery, once the surrounding tissue has healed and the swelling has settled. Some “early-cannulation” graft designs may be used sooner. Your surgeon and dialysis team will tell you when the graft is ready.

Starting Dialysis Through the Graft

The first few dialysis sessions through a new graft are done carefully. Dialysis nurses learn the pattern of the graft — the direction of flow, the best puncture sites — and a rotation pattern is established so that the same area is not punctured repeatedly. Rotating sites prevents weakening of one spot in the graft wall.

Risks and Complications

AV grafts work well for many patients, but they carry risks both around the time of surgery and over the long term. Knowing the main complications helps you spot problems early.

Early Complications

• Bleeding or haematoma at the surgical sites
• Wound infection, which can sometimes involve the graft itself
• Early thrombosis (clotting) of the graft, which may require a procedure to restore flow
• Swelling of the hand or arm, which usually settles but can occasionally persist
• Pain or numbness in the hand if blood flow is reduced beyond the graft, a condition sometimes called “steal syndrome”

Longer-term Complications

• Stenosis (narrowing), usually at the vein end of the graft, which slows flow and can lead to clotting if untreated. Stenosis is the most common reason grafts need maintenance procedures.
• Thrombosis (clotting) of the graft, often on the background of an underlying stenosis. Doctors can often restore flow with a procedure called declotting or thrombectomy.
• Infection of the graft, which is more common with synthetic grafts than with native fistulas and can sometimes require removal of part or all of the graft
• Pseudoaneurysm — a bulge in the graft wall, usually at a repeatedly punctured site
• Steal syndrome — reduced blood flow to the hand, causing coldness, pain, numbness, or in severe cases tissue damage; usually treatable with a procedure to adjust flow
• Heart strain, since the extra blood flow through the access adds to the heart’s workload; relevant especially in patients with existing heart disease

Compared with AV Fistulas

On average, AV grafts have shorter functional lifespans and higher rates of infection and intervention than well-functioning AV fistulas. They typically need more maintenance procedures over time to keep them working. This is one of the reasons fistulas are generally preferred when feasible, even though grafts are a vital option for many patients in whom fistulas are not possible.

Life After AV Graft Placement

An AV graft becomes part of your daily life. With good habits, many grafts function for years.

Looking After the Access Arm

• Do not allow blood pressure measurements, IV lines, or blood draws on the access arm
• Avoid tight clothing, watches, or jewellery on that arm
• Do not sleep on the arm or lie with weight on it for long periods
• Do not carry heavy bags on the access side
• Keep the skin over the graft clean

Checking the Graft Daily

Most patients learn to feel for the thrill over the graft — a constant buzzing vibration that confirms blood is flowing through it. Checking once or twice a day, especially in the morning, helps catch problems early. If the thrill is weaker than usual, has changed in character, or has disappeared, contact your dialysis or vascular team without delay. Early intervention can often save a graft that has just clotted.

Signs That Need Urgent Attention

• Sudden loss of the thrill or change to a different sensation
• Increasing swelling, redness, warmth, or pain at the graft site
• Pus or discharge from the skin
• Fever or chills, especially after dialysis
• A new lump, bulge, or pulsating swelling over the graft
• A cold, painful, numb, or pale hand
• Heavy bleeding from the graft site (apply firm pressure and seek emergency care)

Routine Monitoring

Dialysis units monitor graft function during each session by checking flow patterns, pressures, and the appearance of the access. Periodic ultrasound or other imaging may be done to look for early narrowing. When a stenosis is found, a procedure called angioplasty (using a balloon to stretch the narrowed area) can often restore flow before the graft clots. Sometimes a stent is placed.

Dialysis Routine

Most patients with a graft dialyse three times a week, with sessions lasting around four hours, although schedules vary. Between sessions, you can usually continue work, travel, exercise, and most everyday activities, with sensible care for the access arm.

Exercise and Activity

Light to moderate activity is generally encouraged once healing is complete. Contact sports and activities that put direct pressure or impact on the access arm are usually discouraged. Swimming is usually fine once incisions are fully healed and the graft is being used uneventfully, but personal advice from your team is important.

Travel

Many people on hemodialysis travel, with their dialysis sessions arranged in advance at units along their route. The access itself usually does not prevent travel. Travel insurance, medical letters, and arrangements for dialysis are practical points to plan with your nephrology team.

Frequently Asked Questions

How long does an AV graft last?

There is wide variation. Some grafts work for many years with periodic maintenance procedures; others develop problems within months. On average, grafts have shorter lifespans than well-functioning fistulas and often need procedures to maintain flow over time. Your team can give you a more specific estimate based on your situation.

Will the graft be visible?

An AV graft sits just under the skin and may appear as a soft tube-like swelling, particularly in slim arms. Some patients see a visible bulge along the line of the graft; others have it largely hidden depending on body habitus and graft depth.

Will it hurt to have needles inserted into the graft?

Needle placement does cause some discomfort. Many patients describe it as tolerable and report that it becomes more manageable as they get used to the routine. Numbing creams or local anaesthetic sprays may be used. The graft itself does not have nerves the way native tissue does, but the skin above it does.

Can I shower and bathe normally?

Once incisions are fully healed, normal showering is usually fine. Special care is taken on dialysis days, particularly with the puncture sites, which should be allowed to seal properly before exposing them to water. Your team will give specific advice.

What is the difference between an AV graft and an AV fistula?

An AV fistula joins your artery directly to your vein, using only your own tissue. An AV graft uses a synthetic tube to bridge between the artery and vein. Fistulas generally last longer and have lower infection rates but take longer to mature and are not possible for every patient. Grafts can be used sooner and are an important option when a fistula is not feasible.

Can the graft be removed if I get a kidney transplant?

After a successful kidney transplant, the graft is often left in place initially, in case dialysis is ever needed again. If it causes problems — such as recurrent infection, very high flow that strains the heart, or a large bulge — it can be surgically removed or modified. This is a decision made with your transplant and vascular teams.

Can my graft fail completely?

Yes. Grafts can clot beyond rescue, become infected, or develop problems that require their removal. If one graft fails, doctors often work through other sites in a planned sequence so that further access can be created. Preserving veins, watching the access closely, and acting early on warning signs help maximise the life of each access.

Is there anything I should avoid eating or drinking after the surgery?

The graft itself does not require diet changes. However, kidney failure has its own dietary requirements — including limits on potassium, phosphate, salt, and fluid — and these continue as part of your overall dialysis care. Your nephrologist and renal dietitian guide this.

Conclusion

An AV graft is one of the main ways to create reliable, long-term access to the bloodstream for hemodialysis. For patients whose veins cannot support a fistula, or who need to start dialysis sooner than a fistula could mature, a graft can be the access that keeps treatment safe and consistent over years.

Living well with an AV graft is partly about the surgery itself and partly about the daily habits that protect it: keeping the access arm free of pressure and needles, checking the thrill regularly, watching for changes, and reporting problems early. Working closely with your nephrology, dialysis, and vascular surgery teams gives the graft the best chance of long, trouble-free function — and supports the wider goal of keeping you well while you live with kidney failure or wait for a transplant.