Introduction

Pelvic congestion syndrome (PCS) is a condition associated with abnormal blood flow within the veins of the pelvis. When blood pools within these veins, they may become enlarged and contribute to chronic pelvic pain, pelvic heaviness or pressure.

Pelvic congestion syndrome can be difficult to recognise because chronic pelvic pain has many possible causes. The presence of enlarged pelvic veins on an imaging scan does not necessarily mean that pelvic congestion syndrome is responsible for a person's symptoms.

At the Supreme Vascular and Interventional Clinic, Dr. Manish Tanjea, our vascular and interventional specialist, assesses pelvic venous conditions in the context of your symptoms, medical history and imaging findings to help determine whether abnormal pelvic venous blood flow may be contributing to your symptoms.

Overview

• Haemodialysis access can include an arteriovenous fistula, arteriovenous graft or dialysis catheter.
• Access may malfunction because of narrowing, thrombosis, poor blood flow or other complications.
• Warning signs can include difficulty during dialysis, reduced blood flow, swelling, prolonged bleeding or changes in the access.
• Imaging and vascular assessment can help identify the underlying problem.
• Selected access problems can be treated using minimally invasive procedures to restore or maintain dialysis access.

Haemodialysis Access Malfunction at a Glance

• Haemodialysis access can include an arteriovenous fistula, arteriovenous graft or dialysis catheter.
• Access may malfunction because of narrowing, thrombosis, poor blood flow or other complications.
• Warning signs can include difficulty during dialysis, reduced blood flow, swelling, prolonged bleeding or changes in the access.
• Imaging and vascular assessment can help identify the underlying problem.
• Selected access problems can be treated using minimally invasive procedures to restore or maintain dialysis access.

What Is Haemodialysis Access Malfunction?

Haemodialysis access malfunction occurs when the vascular access used for dialysis does not function as expected. This may affect the ability to obtain adequate blood flow for dialysis and can sometimes require prompt assessment and intervention.

Problems can affect different types of dialysis access:

Arteriovenous Fistula

An arteriovenous fistula (AV fistula) connects an artery and vein to create durable vascular access for haemodialysis.

Arteriovenous Graft

An arteriovenous graft uses a synthetic or biological conduit to connect an artery and vein when a suitable fistula cannot be created or maintained.

Dialysis Catheter

A dialysis catheter provides temporary or, in selected circumstances, longer-term vascular access for haemodialysis. Catheter-related problems may include blockage, poor flow or infection.

Symptoms of Haemodialysis Access Problems

Access malfunction may become apparent during dialysis or through changes around the access site.

Possible signs include:

• Reduced or inadequate blood flow during dialysis
• Difficulty cannulating the access
• Changes in the usual vibration or “thrill” of a fistula
• Swelling of the arm or limb
• Prolonged bleeding after dialysis
• Pain or discomfort around the access
• A dialysis catheter that does not provide adequate flow
• Recurrent problems with dialysis adequacy

A sudden loss of flow or other significant change in a functioning fistula or graft should be assessed promptly.

What Causes Haemodialysis Access Malfunction?

Haemodialysis access can malfunction for several reasons, including:

• Stenosis (narrowing) within or around the fistula or graft
• Thrombosis (blood clot formation) that blocks the access
• Central venous obstruction, which can restrict blood drainage from the access
• Changes in blood flow through the access over time
• Problems affecting a dialysis catheter
• Other structural or access-related complications

How Is Haemodialysis Access Malfunction Diagnosed?

Assessment may include:

• Review of dialysis records and access performance
• Physical examination of the fistula or graft
• Assessment of blood flow and the access “thrill”
• Duplex ultrasound
• Fistulography or other contrast imaging when required
• Assessment of a dialysis catheter where applicable

The findings help determine whether the problem is caused by narrowing, thrombosis or another access complication.

Haemodialysis Access Treatment Options

Treatment depends on the type of vascular access, the underlying problem and the patient's dialysis requirements. Selected patients may benefit from minimally invasive procedures to create, maintain or restore reliable dialysis access.

Haemodialysis Line Insertion

A haemodialysis catheter, sometimes called a dialysis line, is a soft plastic tube inserted through the skin into a large vein, commonly in the neck or upper thigh/groin area. It may provide temporary or longer-term vascular access for patients who require haemodialysis.

Fistulogram and Angioplasty

A fistulogram is a specialised X-ray examination that uses contrast dye to assess blood flow through an arteriovenous fistula or graft and identify areas of narrowing or other problems. When significant narrowing is identified, angioplasty may be performed during the same procedure to widen the affected vessel and improve blood flow.

Endovascular AV Fistula (EndoAVF) Creation

Endovascular arteriovenous fistula (EndoAVF) creation is a minimally invasive approach to creating an arteriovenous connection that can be used as vascular access for haemodialysis. It may provide an alternative to conventional surgical fistula creation for selected patients.

Thrombosed Fistula or Graft Declotting

When an arteriovenous fistula or graft becomes blocked by a blood clot, declotting may be performed to remove the clot and restore blood flow. Treatment may also address an underlying narrowing or other access problem that contributed to the thrombosis.

Central venous obstruction is an important complication that can affect patients receiving haemodialysis, particularly those with a history of central venous catheters or other vascular access procedures. Depending on the location and severity of the obstruction, minimally invasive treatments may be considered to improve venous blood flow and preserve dialysis access.

Does Haemodialysis Access Malfunction Always Require Treatment?

Not every access problem requires an intervention. The appropriate approach depends on the cause, severity of the malfunction, dialysis requirements and condition of the access.

Some problems may be monitored or managed through dialysis-access care, while significant narrowing or thrombosis may require an endovascular procedure to restore adequate blood flow.

Early assessment can be important because a failing access may become more difficult to salvage if the underlying problem is not addressed.

When Should I See a Specialist?

Specialist assessment may be appropriate if:

• Your dialysis access is no longer working normally
• Blood flow during dialysis has decreased
• Your fistula or graft has become difficult to use
• The usual thrill or vibration has changed or disappeared
• Your access repeatedly develops problems
• You have swelling or discomfort around the access
• You have been told that your fistula or graft is narrowed or blocked
• A dialysis catheter is not providing adequate flow

A sudden loss of function of an established fistula or graft should be assessed promptly.

Haemodialysis Access Assessment in Singapore

Patients in Singapore experiencing problems with a haemodialysis fistula, graft or catheter can seek specialist assessment to identify the cause of access malfunction and determine whether minimally invasive treatment may help restore or maintain dialysis access.

At the Supreme Vascular and Interventional Clinic, Dr. Manish Taneja provides specialist vascular and interventional assessment for selected haemodialysis access problems. Assessment may include reviewing dialysis performance, previous access procedures, symptoms and relevant ultrasound or other vascular imaging.

Where appropriate, minimally invasive procedures such as fistuloplasty, clot removal or dialysis catheter insertion may be considered based on the underlying problem and the patient's individual clinical needs.

Frequently Asked Questions