our vascular surgeon believes that a newly created fistula can mature on its own without the need to exercise it. He feels that the arterialization of the vessel alone will expand it sufficiently. I was always taught to have the patient exercise the arm to help mature the fistula. Any help to clear up this debate would be sincerely appreciated!

It won't hurt the access to have the patient exercise it. I don't understand your vascular surgeons objection.

Hi Rachel, rn
Thank you for your response. Our surgeon has it firmly stuck in his mind that arterialization of the vessel is enough to mature the fistula. Do you know of any articles out there that document the advantage of exercising the new fistula? That would really help my cause! I'm still instructing my staff to tell patients to exercise their new fistulas despite what the surgeon has said.

This is directly from K-DOQI guidelines regarding vascular access maturation:

Clinical Practice Guidelines for Vascular Access
Guideline 9 - Access Maturation

A. A primary AV fistula is mature and suitable for use when the vein's diameter is sufficient to allow successful cannulation, not sooner than 1 month (and preferably 3 to 4 months after construction. (Opinion)

B. The following procedures may enhance maturation of AV fistulae:

1. Fistula hand-arm exercise (e.g.,squeezing a rubber ball with or without a lightly applied tourniquet)will increase blood flow and speed maturation of a new native AV fistula. (Opinion)

2. Selective obliteration of major venous side branches will speed maturation of a slowly maturing AV fistula. (Opinion)

3. When a new native AV fistula is infiltrated (i.e., presence of hematoma
with associated induration and edema), it should be rested until swelling is resolved. (Opinion)

C. PTFE dialysis AV grafts should not routinely be used until 14 days after
placement. Cannulation of a new PTFE
dialysis AV graft should not routinely be
attempted, even 14 days or longer after
placement, until swelling has gone down enough to allow palpation of the course of the graft. Ideally, 3 to 6 weeks should be allowed prior to cannulation of a new graft. (Opinion)

D. Patients with swelling that does not
respond to arm elevation or that persists
beyond 2 weeks after dialysis AV access
placement should receive a venogram or other
non-contrast study to evaluate central veins.
(Opinion)

E. Cuffed and noncuffed hemodialysis
catheters are suitable for immediate use and
do not require maturation time. (Evidence)

Although this isn't exactly what you want, perhaps this will be enough information to allow you to continue allowing nurses to encourage exercise of the access. If you don't have a copy of the K-DOQI guidelines for access, you can link to them from the resource list on this home page.

Good Luck,
Carol

I thought you might be interested to know that there was a discussion on this very subject in June on one of the medical nephrology sites.
The conclusion was that there was no evidence to support that exercise had a positive effect on the course of the maturation of the fistula. The other point of view was that it did no harm and kept the patients aware of their new access. Rick Mishler M.D. of Lifeline Vascular Lab, Phoenix AZ. felt that normal daily activites were likely to do as much to develop the fistula as using a ball. There was one reference mentioned in the discussions, which showd no benefit of exercise.
'Rodriguez Moran M,et al. Hand exercise effect in maturation and blood flow of dialysis arteriovenous fistulas ultrasound study.' Angiology 1984:35(10):641-4.
Hope this is of some interest.

Hello Carol,
Thank you so much for your reply! I am going to copy those DOQI guidelines for our surgeon and see what he thinks. In the meantime, I'll continue to have my staff encourage patients to exercise the fistulas.
Thanks again.
Reet

Hello Andrea,
Thank you for your reply! I am going to research that article. Interesting that in all my years as a dialysis nurse, it's been drummed into my head to have patients exercise new fistulas and now it looks like it really doesn't matter if they do or not.
Well, you learn something new everyday!
Thanks again,
Reet