Difficult Graft cannulation

My husband probably has one of the most difficult arterial grafts to cannulate. He is a large man (140k) and we have been doing HHD for over 3 yrs. At the present time we are waiting for a right arm wrist A/V fistula to mature due to an unusual problem with his left forearm loop graft (top arterial) which is a whole different long & frightening story. Right now we are trying to preserve his LFA Graft as long as possible but with almost every cannulation I get blood clots in the eye of the needle. Most are to large to pull with saline (even with wet sticks) resulting with multiple sticks. His graft goes from shallow to deep and back again but almost always with clots. Are there any tips or tricks to prevent this from happening? He just had another angio and usually has narrowing by his pacemaker wires. We do use cushion cannulation and due to the depth of his graft we need the 1" 15G needles. Also, although we do HHD he has occasionally been in-center and hospitalized and I am not the only one that finds him hard to cannulate. Any tips or ideas you can offer?

Use the wet cannulation with 5cc normal saline. When you feel the pop instead of pulling back push forward with 1cc normal saline. This will clear the needle tip of any clotting that has taken place. In most case when clotted are notice it is because the needle has scraped against the vessel wall, it is more prevalent in AV/f than grafts i have seen both. The body response with fibrin to repair the damage. Try a flatter angle 10 degree to 15 degree angle, Please responded after you have try this so that others can follow you lead.

Thank You
Stuart Mott

How did it go? How long has your husbands AVf been in and most important what exercise does he use.

Thought I did this…but don’t see it posted.
First cannulation of Mike’s LFA graft with wet stick did not work. Had to pull needle & found large clock in eye & hub of needle. The 2nd wet stick worked, had good flashback, push & pull with heparin syringe BUT during Tx pressures kept rising. I readjusted needle, propped it, and even tho I hate to, I finally flipped it. The pressures would go down and then started to rise to an unacceptable range. Finally we did an early end.
His new Right arm A/V fistula was done 4/16 but not maturing as well as we hoped. He faithfully exercises it with a rubber ball and is scheduled for an angio the end of this month if all goes well. Getting ready to do another treatment today so will keep you posted. FYI - we have excellent Neph and HHD team but can always appreciate other opinions.

Ok it sounds and fells like he is not getting enough heparin during the tx. What leads to believe this is the slow rise in the venous pressure. How does his dialyzer and blood line look after TX. Did you push 1cc of normal saline on the first cannulation?

Exercise the AV/f using one, two, three, four five PDS weight devolved by dialysis Joe in VA hospital. Joe swears by this method as well as I have seen results. After two weeks and starting in the third week start using a one Pound weight like you are pounding nails in to a wall. The four week you move up to the two pds weight and one pds per week thereafter. if you have ever seen a carpters arm you will see that they have large well devolved veins that’s because the use of the arm. Do ten reps ten times per day this should help to developed the vessel a lot faster.


I again did the wet saline stick and yes, injected about 1 cc saline before pulling back on syringe. First stick did not work and resulted in clot in eye of needle again. Second stick went better and I actually pulled the clot and was able to use the site. However, about 2 hrs. into treatment A/P were rising uncontrollably. I reduced BFR to 300 and even used an interim bolus of heparin but even with needle propping, etc. could not get pressures to normal. So again did an early end with the filter being clear. We had to cut down on our heparin use due to a former abscess on an old angioplasty site (2/20) that resulted in a rupture (4/16) that caused a serious bleeding incident. I will dig out the hand weights and let him start pounding invisible nails…we really need that A/V fistula to work. Thanks for your prompt reply.

He just had another angio and usually has narrowing by his pacemaker wires. this i copy from your frist e-mial. What do you mean by pacemaker wires?

Mike has a pacemaker and gets a narrowing clear up his arm and into the area where his pacemaker wires are. He has had more than his share of angioplasties. He is also being treated for bladder cancer so we really don’t need anymore problems.

ok understand now keep working on the AV/f and when will they think it will be ready for canulation?

We go at the end of this month to check on it but with the problems we are having I doubt if we wait that long.