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Achilles Tendonitis Stretches & Exercises for Early-Stage Pain
A dull ache above the heel after a run. Morning stiffness in the back of the ankle that eases once you get moving around
Medically Reviewed by
Dr. Paul Hanna, DO, RPVI
Board Certified Vascular Surgeon
Anyone facing hemodialysis eventually runs into the same decision: what kind of vascular access will carry blood to and from the dialysis machine, safely and repeatedly, several times a week for years to come. The two most common permanent options are an AV fistula and an AV graft, and the choice between them affects everything from how soon dialysis can start to how many complications a patient is likely to face over the years ahead.
Both create a durable connection between an artery and a vein so that a needle can access a strong, high-flow blood vessel during each dialysis session. Beyond that shared purpose, the two options differ in construction, timeline, durability, and risk in ways that matter a great deal for long-term kidney care.
An AV fistula, short for arteriovenous fistula, is created by surgically connecting an artery directly to a nearby vein, most commonly in the forearm or upper arm. Once connected, the higher pressure and blood flow from the artery causes the vein to gradually enlarge and thicken, a process called maturation, until it’s strong enough to tolerate repeated needle insertions during dialysis.
Because a fistula uses a patient’s own blood vessels rather than any synthetic material, it’s widely considered the gold standard for dialysis access. It tends to last longer and develop fewer complications than the alternatives, which is why vascular surgeons generally try to use a fistula whenever a patient’s blood vessels are suitable for one.
In plain terms, a fistula for dialysis is essentially a permanent, natural highway built from the patient’s own tissue. It replaces the need for an artificial tube by upgrading a vein to handle a much higher volume of blood flow than it normally would.
This natural quality is exactly what gives fistulas their durability advantage. Because the body’s own healing and remodeling processes strengthen the vessel over time, a well-matured fistula can function for years, sometimes decades, with proper care, making it the option most nephrologists and vascular surgeons hope to use whenever possible.
An AV graft serves the same basic purpose as a fistula, creating a durable access point for dialysis, but it’s built differently. Instead of connecting an artery directly to a vein, a surgeon places a short length of synthetic tubing, usually made of a material called PTFE, to bridge the artery and vein together.
Grafts are typically used when a patient’s veins aren’t large or strong enough to develop into a functional fistula on their own. Because the connection doesn’t rely on a vein maturing and strengthening naturally, a graft can often be used for dialysis sooner than a newly created fistula can.
One of the most practical differences between a fistula and a graft is how soon each can be used after surgery. A fistula typically needs six weeks to several months to mature properly before it’s ready for regular needle access, since the vein needs time to thicken and strengthen under the new blood flow.
A graft, by contrast, can often be used within two to three weeks of placement, and in some cases even sooner. This shorter maturation window is one of the main reasons grafts are chosen for patients who need to start dialysis more urgently and don’t have time to wait for a fistula to fully mature.
Fistulas generally outperform grafts over the long run. Because they’re built from the patient’s own vessel, they tend to develop fewer clots and infections, and a well-functioning fistula can remain usable for many years with appropriate care and monitoring.
Grafts, while a valuable option, tend to have a shorter overall lifespan and a higher rate of complications like clotting and narrowing at the connection points. They often require more frequent interventions to keep them functioning well, including procedures to clear blockages or repair narrowed segments, sometimes more than once a year depending on the individual case.
Infection risk is another meaningful difference between the two options. Because a fistula uses only the patient’s own vein and artery with no foreign material involved, it carries a lower baseline risk of infection compared to a graft.
A graft, being a synthetic implant, provides a surface where bacteria can potentially take hold more easily than natural vessel tissue does. This doesn’t mean graft infections are common or expected, but it’s a real factor that vascular surgeons weigh when discussing candidacy and long-term care between the two options with patients.
Fistulas work best in patients with veins that are large enough and healthy enough to mature properly, which is why a vascular surgeon typically performs an ultrasound mapping of the arm’s blood vessels before deciding which option to recommend. Younger patients and those with healthier blood vessels overall are often good fistula candidates.
Grafts become the more practical choice when a patient’s veins are too small, too fragile, or previously damaged from prior IV lines or blood draws to support a fistula. Patients who need to start dialysis urgently, before a fistula would have time to mature, may also start with a graft, sometimes transitioning to a fistula later if their vessels allow for it.
Neither a fistula nor a graft can be used immediately after placement, which means many patients start dialysis using a temporary central venous catheter while their permanent access matures. Catheters can be used right away, but they carry a meaningfully higher risk of infection and clotting compared to either a fistula or a graft, which is why they’re generally intended as a bridge rather than a long-term solution.
Minimizing the amount of time spent relying on a catheter, by planning fistula or graft placement as early as possible once kidney function is declining, is one of the more important goals in comprehensive dialysis access planning, and one worth discussing with a nephrologist well before dialysis is actually needed.
Once matured, both a fistula and a graft are accessed with two needles at each dialysis session, one to carry blood to the machine and one to return it to the body. Patients are generally advised to protect the access arm from tight clothing, blood pressure cuffs, and heavy lifting, and to check the area daily for a normal humming or buzzing sensation called a thrill, which indicates healthy blood flow.
A change in that sensation, along with new swelling, redness, or pain around the access site, should be reported to a care team promptly, since catching a developing problem early often allows for a simpler fix than waiting until the access fails entirely and requires a more involved repair or an entirely new access site.
The decision between a fistula and a graft isn’t one-size-fits-all. A vascular surgeon considers vein size and quality, artery health, how urgently dialysis needs to begin, a patient’s overall health and life expectancy, and any history of prior vascular access or central line placement that might affect available options.
This is why an individualized evaluation, usually including a vascular ultrasound, matters so much before deciding on the right access type. What worked well for a family member or friend on dialysis isn’t necessarily the right choice for another patient with different vessel anatomy.
Dialysis access isn’t a one-time decision that gets made and forgotten. It becomes part of a patient’s ongoing care for as long as they’re on hemodialysis, and a well-functioning access point directly affects how efficient and comfortable each dialysis session is.
Choosing the option best suited to a patient’s individual anatomy and circumstances, rather than defaulting to the same choice for everyone, reduces the number of procedures needed to maintain access over time and supports better long-term outcomes overall, both medically and in terms of day-to-day quality of life on dialysis.
For anyone with declining kidney function who may eventually need dialysis, protecting the veins in one arm, usually the non-dominant arm, ahead of time gives a vascular surgeon far more options later. This means avoiding routine blood draws, IV placements, and blood pressure cuffs on that arm whenever possible, since repeated needle sticks and pressure can damage or scar the very veins that might otherwise mature into a good fistula.
Many nephrology practices flag this vein preservation step early in the course of chronic kidney disease, well before dialysis actually becomes necessary. Patients who aren’t yet on dialysis but know it may be in their future can ask their care team which arm to protect, since this single, low-effort habit can meaningfully expand which access options remain available when the time comes, sometimes making the difference between qualifying for a fistula or needing a graft.
Before either procedure, a vascular surgeon typically orders an ultrasound of the arm’s veins and arteries, sometimes called vessel mapping, to identify which vessels are healthy enough and large enough to support a fistula, or whether a graft is the more realistic option. This mapping step is what actually drives the decision between the two, more than a patient’s general preference or what worked for someone else they know on dialysis.
The surgery itself is usually done as an outpatient procedure under local or regional anesthesia, often completed within an hour or two depending on the complexity of the case. Recovery from the initial surgery is generally straightforward, with most patients resuming normal daily activities within a few days, well before the access itself is mature enough to actually use for dialysis sessions.
Both AV fistulas and AV grafts are standard, well-established procedures typically covered by Medicare and most private insurance plans as part of dialysis access care, since having functional vascular access is considered medically necessary for anyone requiring hemodialysis. Specific coverage details can still vary by plan, so confirming coverage ahead of a scheduled procedure is a reasonable step.
Because grafts sometimes require more frequent follow-up procedures to maintain function over time, compared to a well-matured fistula, the cumulative cost of care over several years can end up higher for grafts in some cases. This is one more practical factor, beyond the purely medical considerations, that can play into a longer-term access planning conversation with your care team and your insurance provider.
If you or a family member is approaching the need for dialysis, or if an existing fistula or graft is showing signs of trouble, like reduced flow, swelling, or difficulty with needle placement, a vascular surgeon experienced in dialysis access can evaluate your vessels and recommend the most appropriate option.
Our vascular surgery team manages dialysis access planning and complications regularly and can walk you through which option, fistula or graft, fits your specific anatomy and timeline, ideally well before dialysis becomes urgent. Learn more about our approach to dialysis access management in Miami.
An AV fistula and an AV graft both create a durable access point for hemodialysis, but they differ meaningfully in how they’re built, how soon they can be used, and how long they tend to last. Fistulas generally offer better longevity and lower infection risk, while grafts provide a faster path to usable access when veins aren’t suitable for a fistula or when dialysis needs to start sooner. The right choice depends on individual vessel anatomy and circumstances, which is why this decision is best made with a vascular surgeon evaluating your specific case rather than assuming one option is universally better for every patient.
AV fistulas generally last longer than grafts, often functioning well for many years, since they’re built entirely from the patient’s own tissue and tend to develop fewer complications like clotting and infection over time.
Most fistulas need six weeks to several months to mature properly before they can be used reliably for dialysis, depending on how quickly the vein strengthens and enlarges after surgery.
Yes, in some cases. If a patient started with a graft due to urgent dialysis needs, a vascular surgeon may evaluate whether their vessels have since become suitable for a fistula as a longer-term option.
Generally, yes. Because a graft involves synthetic material, it carries a somewhat higher infection risk than a fistula, which uses only the patient’s own blood vessels.
A thrill is the buzzing or humming sensation felt over a properly functioning fistula or graft, caused by healthy blood flow through the access. A change or absence of this sensation can signal a developing problem and should be reported promptly.
Hemodialysis Access, National Kidney Foundation
AV Fistula vs. AV Graft: Understanding the Two Main Types of Dialysis Access, Vascular Specialists
Dr. Paul Hanna is a board-certified vascular surgeon with specialized fellowship training in complex vascular interventions and minimally invasive endovascular techniques. He serves as Director of Vascular Surgery and General Surgery at South Florida Multispecialty Medical Group, with over a decade of experience treating vascular conditions affecting the limbs, aorta, and peripheral arterial system.
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