Access

• Tunneled dialysis catheter (TDC) in the IJ if requires immediate dialysis
• Never placed in the subclavian - stenosis/thrombosis will make the ipsilateral arm unusable for future access
• AV fistula in non-dominant arm for permanent dialysis access
• Takes 6-8 weeks to mature. Should ideally create months in advance, but may use TDC in meantime while waiting for fistula to mature.
• "Rule of 6": 6 cm in usable length, 6 mm wide, < 6 mm from skin surface, 600 cc/min flow rate
• In patients with ESRD or impending dialysis needs, make every effort to preserve forearm veins - use veins distal to wrist, or in neck/legs

AV fistula

• Pre-op vein mapping
• Main candidates are cephalic or basilic veins, and brachial or radial artery
• Vein should be at least 3-6 mm width for a significant length. 
• Should palpate thrill and auscultate bruit
• Pain in hand, numbness/tingling, weakness can indicate vascular steal syndrome - fistula "steals" blood supply from ulnar/radial arteries and decreases perfusion to the hand. 
• Evaluate with duplex ultrasounds, waveforms/pressures
• Symptoms typically appear as the fistula progresses, e.g. over weeks
• Immediate onset of symptoms can be 'ischemic monomelic myopathy' = ischemia to peripheral nerves causing deficit - may still have warm hand/+radial pulse. Very rare