Synopsis
Recognise clinical fistula dysfunction before occlusion, confirm the lesion through timely circuit imaging, and salvage acute thrombosis by removing thrombus and correcting the culprit stenosis.
- An abruptly absent thrill or bruit is a time-sensitive thrombosed access: stop repeated cannulation and obtain same-day dialysis and access-team review for salvage.
- Salvage must address both thrombus and the underlying culprit stenosis; thrombectomy without lesion treatment invites early re-occlusion.
- Treat stenosis when clinical dysfunction and a radiologically significant lesion agree; do not perform pre-emptive angioplasty for an incidental narrowing without clinical indicators.
Key red flags
Absent thrill or bruit is acute thrombosis until proved otherwise and should trigger same-day access assessment rather than routine outpatient imaging.
Severe hyperkalaemia, pulmonary oedema, uraemic complication or missed essential dialysis requires parallel emergency dialysis planning through safe alternative access.
A painful erythematous thrombosed access with fever or purulence may be infected; obtain blood cultures and avoid blind declotting through an infected field.
Rapid swelling, neurological deficit or hand ischaemia after intervention suggests bleeding, compartment pressure, embolisation or arterial injury and needs urgent vascular review.
Sudden loss of the continuous thrill and bruit, a firm non-compressible segment and inability to aspirate blood are typical; pain may be modest, so absence of pain is not reassuring.
Fever, rigors, purulent drainage, erythema, fluctuance or exposed material accompanying thrombosis raises a different emergency because declotting may disseminate infection.
Investigation priorities
Confirm thrill or bruit loss, examine the whole circuit and limb, check last successful dialysis, volume state and urgent biochemical need.
Locate thrombus, quantify inflow and outflow, identify stenosis, aneurysm or collection, and assess adjacent arteries and veins without iodinated contrast.
Management branches
Use for a previously functioning fistula with absent thrill or bruit, failed cannulation or confirmed acute thrombotic occlusion.
- Stop repeated needling, establish last dialysis and biochemical urgency, examine for infection, limb ischaemia, swelling and bleeding, and alert the access team the same day.
- Arrange urgent duplex or direct procedural imaging and choose endovascular or surgical salvage according to anatomy, expertise, infection, prior treatment and the person's access plan.
Use for new cannulation difficulty, abnormal examination, prolonged bleeding, falling adequacy, pressure alarms or arm swelling while flow persists.