The Infected Access

Both arteriovenous hemodialysis grafts (AVGs) and fistulas (AVFs) can become infected. The clinical presentation can range from mild cellulitis to overwhelming sepsis. The diagnosis is usually evident on physical examination but can be corroborated with duplex ultrasound. AVF infections are commonly focal and result from aneurysms/pseudoaneurysms, buttonhole cannulations, or infected hematomas while AVG infections can be either focal or more diffuse. Staph. aureus and epidermidis are responsible for the majority of infections although any organism can be implicated with the incidence of Gram-negative organisms higher for lower extremity access infections. Treatment goals include infection control, access salvage, and preservation of future access options. Empiric parenteral antibiotics are initiated at the time of diagnosis and refined based upon the culture results. Definitive surgical treatment is dictated by the extent of the infection, the type of access, the location of the access, comorbidities, and future access options. Localized AVG and AVF infections can often be treated with access salvage if there is a sufficient uninvolved segment of the access for cannulation. Infections that involve the whole access, typically AVGs, require access abandonment with either a total or subtotal excision of the prosthetic material. Total graft excision is favored although subtotal excision may be appropriate in certain settings given the technical challenges of arterial revascularization.