https://www.kidney.org/sites/default/files/Fistula%20Bulletin.pdf

Arteriovenous fistula (AVF) catheter placement is a routine procedure in hemodialysis, but improper technique or inadequate management may lead to a series of complications-ranging from impaired dialysis efficiency to AVF failure, which can endanger patients' lives. Therefore, systematically preventing, early identifying, and properly managing these complications are essential competencies in dialysis nursing. This article focuses on AVF catheter insertion and provides a detailed overview of the prevention and control system for related complications.

1. Prevention and Control of Immediate Complications

• Hematoma at the puncture site: This is the most common complication. Prevention hinges on accurate puncture, avoiding repeated punctures at the same site or penetrating through the posterior vessel wall. Using sharp, smooth-surfaced needles (such as those precision-ground and electrolytically polished) effectively reduces vascular injury. Proper compression after puncture is crucial. Management: Immediately remove the needle, apply direct pressure to control bleeding, use cold compresses within 24 hours, and switch to warm compresses after 24 hours to promote absorption. Assess whether the hematoma is compressing the fistula and affecting blood flow.
• Puncture failure or inadvertent arterial/venous access: Commonly occurs with poor vascular conditions or inaccurate positioning. Prevention: Rely on ultrasound assessment and ultrasound-guided puncture (UGP). Management: Immediately withdraw the needle and apply firm pressure. Reassess the vessel and consider changing the puncture site if necessary.
• Inadequate blood flow: Manifests as difficulty in blood return or excessive negative pressure in the artery. Causes include needle tip adhering to the vessel wall, partial dislodgement, vasospasm, or stenosis. Prevention: Ensure the puncture needle is centered within the vessel lumen and securely fixed. Selecting needles with optimized side-hole design may improve hemodynamics and reduce wall adhesion. Management: Gently adjust the angle or depth of the needle; for vasospasm, apply local heat; for stenosis, further evaluate the arteriovenous fistula.

II. Prevention and Control of Early and Late Complications

Infection: Includes local infection at the puncture site, which may lead to bacteremia and even endocarditis. Prevention is key, requiring strict adherence to aseptic techniques. Using disposable sterile needles that have undergone rigorous cleaning (e.g., ultrasonic cleaning) and sterilization prior to shipment forms the foundation for preventing exogenous infections. Patient education on personal hygiene is essential. Management: Local infections can be treated with topical antibiotic ointments; systemic symptoms require immediate administration of appropriate antibiotics, along with assessment of whether the graft (e.g., synthetic vascular fistula) should be removed.

• Aneurysm/Pseudoaneurysm formation: Primarily results from repeated regional punctures causing vessel wall weakening and dilation. Prevention: Strictly follow the "rope ladder" technique and rotate puncture sites regularly. Avoid puncturing directly into an existing aneurysm. Management: Small aneurysms may be managed with compression bandages to prevent further punctures in the area; large or high-risk aneurysms requiring surgical repair.
• Vascular stenosis: Commonly occurs at sites of repeated puncture (intimal hyperplasia) or at anastomotic sites. Prevention: Employ precise and gentle puncture techniques to minimize intimal injury; systematically rotate puncture sites. Management: Regular ultrasound monitoring of blood flow and vessel diameter. Significant confirmed stenosis (diameter reduction >50% with decreased flow) requires percutaneous transluminal angioplasty (PTA) or surgical intervention.
• Thrombosis: The leading cause of acute graft failure. Associated with puncture-related endothelial injury, hypotension, excessive compression, and hypercoagulable states. Prevention: Minimize endothelial damage during puncture; apply proper post-dialysis compression (until thrill is still palpable); manage hypercoagulable conditions. Management: Immediate medical attention is required if thrill and bruit disappear; treatment options include pharmacological thrombolysis, mechanical thrombectomy, or surgical thrombectomy.

3. Building a Systematic Culture of Complication Management

Complication management should extend from single procedures to the entire care process. Establish standardized operating procedures (SOPs) and provide ongoing training for healthcare staff, particularly in ultrasound skills. Create a detailed "fistula passport" for each patient, documenting every puncture site, complications, and interventions. Conduct regular (e.g., monthly) ultrasound monitoring of arteriovenous fistulas. Encourage patients to participate in self-monitoring (daily palpation of thrill).

Conclusion:

Preventing and managing complications associated with AVF catheter placement is a continuous, dynamic process. It relies not only on high-performance, minimally invasive medical devices-such as high-quality puncture needles-but even more importantly on the operator's standardized techniques, keen observational skills, and systematic management strategies. By prioritizing prevention, early detection, and standardized intervention, we can best safeguard the lifeline for dialysis patients.