Common Complications After Arteriovenous Fistula (AVF) Surgery: What Patients and Caregivers Need to Know

Understanding the Risks of AVF Surgery

While arteriovenous fistula (AVF) creation remains the gold-standard vascular access for long-term hemodialysis, it's essential to recognize that no surgical procedure is entirely risk-free—even those considered minimally invasive and routinely performed. Although AVF surgery is typically straightforward and completed in under an hour, outcomes depend heavily on patient-specific factors such as native vessel quality, comorbidities (e.g., diabetes, peripheral artery disease), surgical technique, and postoperative care. A successful AVF isn't just about immediate patency—it's about sustained functionality, adequate blood flow, and minimal adverse events over time.

Top 6 Potential Complications—and How to Recognize Them Early

1. Early Thrombosis: The Most Common Cause of Primary Failure

Thrombosis—blood clot formation within the newly created fistula—is the leading cause of early AVF failure, occurring in up to 20% of cases within the first 30 days. Warning signs include sudden loss of the characteristic thrill (a palpable vibration) or bruit (audible humming sound), diminished pulsation, or complete absence of detectable flow during physical exam. Prompt evaluation with Doppler ultrasound is critical; timely intervention—including thrombectomy, angioplasty, or revision—can often salvage the access.

2. Localized Infection: More Than Just Redness and Swelling

Infection at the AVF site may begin subtly but can escalate rapidly. Classic signs—redness, warmth, swelling, tenderness, and purulent drainage—should never be dismissed as "normal healing." Fever, chills, or systemic malaise suggest possible bacteremia or sepsis, especially in immunocompromised or diabetic patients. Early culture-guided antibiotics and, when necessary, surgical debridement are vital to prevent life-threatening complications like endocarditis or metastatic abscesses.

3. Pseudoaneurysm Formation: A Hidden Structural Risk

Unlike true aneurysms, pseudoaneurysms result from a contained rupture of the arterial wall—often due to repeated needle punctures, technical imperfections during anastomosis, or underlying vessel fragility. Patients may notice a soft, pulsatile, enlarging mass near the fistula site—sometimes accompanied by pain or skin thinning. Left untreated, these lesions carry risks of rupture, hemorrhage, or compromised distal perfusion. Ultrasound is the diagnostic tool of choice; treatment options range from ultrasound-guided thrombin injection to surgical repair.

4. Stenosis and Inadequate Blood Flow: The Silent Threat to Long-Term Function

Stenosis—narrowing at the anastomosis, juxta-anastomotic region, or outflow vein—is the most frequent cause of late AVF dysfunction. It often develops insidiously, leading to decreased flow rates (<500 mL/min), prolonged bleeding after dialysis, or difficulty achieving target pump speeds. Surveillance protocols (e.g., monthly clinical assessment + quarterly Doppler or flow studies) help detect stenosis before thrombosis occurs. Percutaneous transluminal angioplasty (PTA) remains first-line therapy—with high technical success and improved patency rates.

5. High-Output Cardiac Failure: When Access Becomes a Cardiovascular Burden

Although rare, large or hyperdynamic AVFs can significantly increase cardiac output—especially in older adults or those with preexisting heart disease. Symptoms like progressive shortness of breath, orthopnea, fatigue, or new-onset edema warrant immediate cardiology consultation. Echocardiography helps quantify shunt volume and ventricular strain. Interventional strategies—including flow reduction via banding, distal revascularization–interval ligation (DRIL), or even AVF ligation—may be required to protect heart function.

6. Steal Syndrome & Hand Ischemia: Swelling, Pain, and Beyond

"Dialysis access steal syndrome" occurs when excessive blood diverts away from the hand through the low-resistance fistula, causing digital pallor, coldness, numbness, or ulceration. Concurrent hand swelling—particularly if asymmetric, persistent, or worsening—may reflect venous congestion, lymphatic disruption, or impaired collateral circulation. Conservative management includes limb elevation, compression gloves, and activity modification. However, severe or progressive symptoms demand urgent vascular evaluation; interventions like proximalization of the arterial inflow (PAI) or revision surgery can restore distal perfusion and relieve edema.

Proactive Monitoring Makes All the Difference

Early detection dramatically improves outcomes. Patients should perform daily self-checks: feel for thrill, listen for bruit (using a stethoscope), inspect for skin changes, and monitor for new swelling or discomfort. Clinicians must integrate routine physical exams, objective flow measurements, and imaging into standard care pathways. With vigilant surveillance and timely intervention, most AVF complications are preventable—or at least manageable—ensuring safer, more effective, and longer-lasting vascular access for people living with kidney failure.