Skip to main content

Health condition · Clinically reviewed

Arteriovenous fistula, from dialysis access to dural AVF - the full picture.

A direct artery-to-vein connection that can be a lifeline for kidney patients or a hidden danger in the head. This guide walks through every kind and how each is treated.

Jump to treatment
A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against NICE, Vascular Society of Great Britain and Ireland, Renal Association and peer-reviewed sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK practice on dialysis access, dural AVF embolisation and endovascular closure of traumatic fistulae.

Key facts

AVF at a glance.

The essentials, in plain English - what an arteriovenous fistula is, the types you might meet, and how each is treated in the UK today.

  • What it is

    A direct connection between an artery and a vein that bypasses the capillary bed, so high-pressure arterial blood flows straight into the venous system.

  • Congenital vs acquired

    Congenital AV malformations are present from birth. Acquired fistulae follow trauma, catheterisation, biopsy or vascular disease.

  • Therapeutic AVF

    A surgeon can create an AVF on purpose for haemodialysis access - the radiocephalic Brescia-Cimino remains the reference standard.

  • Dural AVF

    An intracranial variant involving a dural venous sinus - typically transverse-sigmoid or cavernous - presenting with pulsatile tinnitus, headache or haemorrhage.

  • Core investigations

    Duplex ultrasound first, then CT angiography, MR angiography or catheter angiography as the anatomy demands.

  • Treatment ladder

    Observation for small asymptomatic lesions, endovascular closure for most acquired fistulae, surgery for high-flow or complex disease.

Why this guide matters

Different fistulae, different plans.

A dialysis fistula, a groin fistula after cardiac catheterisation and an intracranial dural AVF all share the same physiology - but each needs a very different team and treatment.

  • Dialysis AVF is a lifeline

    A well-planned autogenous fistula is the best long-term access for haemodialysis - it is worth protecting from day one.

  • Traumatic fistulae usually close from the inside

    Endovascular coils and covered stents have replaced most open repairs for iatrogenic and traumatic AVFs.

  • Dural AVF is a neurointerventional job

    Modern embolisation cures most dural fistulae, and prompt referral prevents catastrophic haemorrhage.

How the diagnosis is made

From a suspicious bruit to a clear treatment plan.

The steps a UK vascular or neurointerventional team will normally follow, in order - so you know what to expect and why.

  1. 01

    Assessing

    History and examination

    A vascular history focused on prior trauma, catheter access, biopsies or a known malformation - then palpation for a thrill and auscultation for a bruit.

  2. 02

    Assessing

    Duplex ultrasound

    First-line imaging - shows flow direction, peak velocities, feeding artery and draining vein, and the size of any aneurysmal segment.

  3. 03

    Assessing

    Cardiac assessment

    A resting ECG and echocardiogram with BNP look for high-output cardiac failure when the shunt volume is large or symptoms suggest strain.

  4. 04

    Confirming

    Cross-sectional angiography

    CT angiography or MR angiography maps peripheral, visceral or pulmonary fistulae and clarifies the vascular territory involved.

  5. 05

    Confirming

    Cerebral DSA for dural AVF

    Digital subtraction angiography is the reference standard for suspected dural AVF - it grades venous drainage and guides embolisation planning.

  6. 06

    Preparing

    Vein mapping for dialysis

    Pre-operative vein mapping ultrasound is standard before creating a haemodialysis AVF - the surgeon needs a vein of adequate calibre and an artery with sufficient inflow.

  7. 07

    Preparing

    Multidisciplinary planning

    Complex or dural cases are discussed at a vascular, interventional radiology and neurointerventional MDT before a definitive plan is offered.

Typical timeline: from a first duplex to a definitive plan in weeks, not months.

Symptoms

What an AVF actually feels like.

Presentation depends on where the fistula sits and how much blood flows through it - a thrill and bruit are common, but the impact ranges from silent to life-threatening.

  • Thrill and bruit

    A palpable buzz over the fistula and a continuous machinery murmur on auscultation - the classic bedside signs.

  • Dilated draining veins

    Tortuous, engorged surface veins downstream from the fistula, often visible in the arm, leg or scalp.

  • Distal ischaemia (steal)

    Cold, painful or numb hand or foot beyond a high-flow fistula - dialysis steal syndrome is the classic example.

  • Venous hypertension and oedema

    Swelling, skin changes and pigmentation from raised venous pressure - can progress to ulceration if untreated.

  • High-output cardiac failure

    Breathlessness, tachycardia and fatigue from a large chronic shunt - often develops insidiously over years.

  • Pulsatile tinnitus (dural AVF)

    A rhythmic whooshing heard in one ear that matches the pulse - a hallmark symptom of a dural AVF.

  • Neurological symptoms

    Headache, visual disturbance, cranial nerve palsies or seizures may point to a cerebral or spinal AVF.

  • Red flag - haemorrhage

    Sudden severe headache, focal deficit or loss of consciousness in a known or suspected AVF is a neurosurgical emergency.

Treatment

How AVFs are treated in the UK.

Observation for small quiet fistulae, endovascular closure for most acquired ones, surgical creation and salvage for dialysis access, and neurointerventional embolisation for dural disease.

  • Observation

    Small, asymptomatic peripheral fistulae with low flow can be safely monitored with periodic duplex ultrasound - many never need intervention.

  • Surgical AVF creation

    A vascular access surgeon fashions a radiocephalic, brachiocephalic or brachiobasilic transposition fistula for haemodialysis, with 6-8 weeks of maturation before use.

  • Arteriovenous graft (AVG)

    A prosthetic graft between an artery and vein - the alternative when native vein anatomy is unsuitable for an autogenous AVF. Faster to use but higher infection and thrombosis rates.

  • Fistuloplasty and stenting

    Endovascular angioplasty, sometimes with a covered stent, is the standard treatment for a stenosis or early thrombosis in a dialysis AVF.

  • Dialysis-access rescue surgery

    DRIL (distal revascularisation and interval ligation), MILLER banding or proximalisation of arterial inflow (PAI) address steal, high output or venous hypertension without sacrificing the fistula.

  • Endovascular closure

    Coil embolisation or a covered stent closes a traumatic or iatrogenic AVF - the first-line approach for most acquired peripheral fistulae.

  • Endovascular embolisation (dural)

    Transarterial or transvenous embolisation with liquid embolic or coils is the modern first-line treatment for most dural AVFs.

  • Open surgery or radiosurgery

    Selective microsurgical disconnection or stereotactic radiosurgery is reserved for dural AVFs unsuitable for endovascular treatment, or when high-flow shunts cause cardiac failure.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP, vascular team or neurointerventional team knows your history and can tell you which parts apply to you. If in doubt, get seen.

  • NICE. Renal replacement therapy and conservative management (NG107).

  • Vascular Society of Great Britain and Ireland. Vascular access for haemodialysis - quality improvement framework.

  • Renal Association / UK Kidney Association. Clinical practice guideline on vascular access for haemodialysis.

  • British Society of Neuroradiologists. Guidance on management of intracranial dural arteriovenous fistulae.

  • European Society for Vascular Surgery (ESVS). Clinical practice guidelines on vascular access.

Red flags

When an AVF needs urgent attention.

Most fistulae are managed in a planned outpatient pathway. These are the situations that aren’t - and where same-day specialist care is needed.

  • Intracranial haemorrhage

    Sudden severe headache, collapse or focal deficit in a known or suspected dural AVF - call 999 and treat as a neurosurgical emergency.

  • Acute limb ischaemia

    A cold, pale, painful, pulseless or paralysed limb distal to a fistula needs same-day vascular review.

  • Bleeding from a dialysis AVF

    Any pulsatile bleeding from a fistula site is an emergency - apply firm digital pressure and go to A&E immediately.

  • Infected fistula or graft

    Fever, redness, discharge or systemic sepsis around a fistula or AVG needs urgent renal and vascular assessment.

  • Rapidly enlarging aneurysm

    A growing pulsatile swelling over an AVF, especially with skin thinning, risks rupture and needs urgent surgical review.

  • New heart failure symptoms

    Breathlessness, orthopnoea or leg swelling in a patient with a large AVF may reflect high-output failure - refer for cardiac and vascular assessment.

  • Progressive neurological signs

    Worsening cranial nerve palsy, visual loss or seizures with a known intracranial AVF warrants urgent neurointerventional review.

  • Cavernous sinus AVF signs

    Red eye, proptosis, ophthalmoplegia and a bruit over the eye suggest a cavernous dural AVF - refer urgently.

  • Post-catheterisation new bruit

    A new bruit or pulsatile swelling after femoral or radial catheterisation should trigger urgent duplex ultrasound.

Living with it

A treatable condition, with a clear ladder.

Four things that make the biggest difference day to day - careful access hygiene, regular surveillance, prompt reporting of new symptoms, and taking head symptoms seriously.

A quiet reminder

Small changes tell you a lot.

A softer thrill, a new swelling or a cooler hand often flag a problem long before dialysis fails. Tell your access nurse early.

  1. 01 Access care

    Look after your fistula every day

    Feel for the thrill each morning, keep the arm clean, and never let anyone take blood, put in a cannula or measure blood pressure on the fistula arm.

  2. 02 Surveillance

    Attend your access clinic

    Regular clinical review and duplex surveillance pick up stenosis early, so a fistuloplasty can save the access before it clots.

  3. 03 Symptoms

    Tell someone about new symptoms

    A cold or painful hand, new arm swelling, breathlessness or a change in the thrill deserves prompt review, not a wait-and-see.

  4. 04 Head signs

    Take head symptoms seriously

    Pulsatile tinnitus, unusual headaches or eye symptoms in someone with a known or suspected dural AVF need urgent specialist input.

Frequently asked

Everything we get asked about AVFs.

Quick answers on dialysis access, dural AVF, traumatic causes and the treatment ladder.

  • What is an arteriovenous fistula?

    An arteriovenous fistula (AVF) is a direct connection between an artery and a vein that bypasses the capillary bed. It can be congenital, acquired after trauma or medical procedures, or surgically created on purpose for haemodialysis access. A dural AVF is an intracranial variant involving one of the dural venous sinuses.

  • How is a dialysis fistula created?

    A vascular access surgeon joins a suitable forearm or upper-arm vein to an adjacent artery, most often at the wrist (radiocephalic Brescia-Cimino) or the elbow (brachiocephalic or brachiobasilic transposition). Pre-operative vein mapping ultrasound checks the anatomy, and the fistula then matures over 6 to 8 weeks before it can be needled for dialysis.

  • What are the main complications of a dialysis AVF?

    The commonest are stenosis, thrombosis, steal syndrome (a cold, painful hand), venous hypertension with arm swelling, aneurysmal dilatation, infection and, in a small proportion, high-output cardiac failure. Regular surveillance and prompt fistuloplasty prevent most access failures.

  • What causes a traumatic or iatrogenic AVF?

    A penetrating injury, a fracture or a medical procedure such as femoral or radial catheterisation, arterial line insertion or renal biopsy can create an abnormal connection between an artery and an adjacent vein. Most are now closed with endovascular coils or a covered stent rather than open surgery.

  • What is a dural arteriovenous fistula?

    A dural AVF is an abnormal connection between an artery in the dura and a dural venous sinus, most often the transverse-sigmoid or cavernous sinus. Typical symptoms include pulsatile tinnitus, headache, red eye or, in higher-grade lesions, seizures or intracranial haemorrhage. Cerebral angiography (DSA) is the reference investigation.

  • How is a dural AVF treated?

    Endovascular embolisation, delivered either transarterial or transvenous, is the first-line treatment for most dural AVFs. Stereotactic radiosurgery is an option for smaller low-grade lesions, and open neurosurgical disconnection is reserved for cases unsuitable for embolisation. Treatment is planned by a neurointerventional MDT.

Related content

Keep reading.

Pulse Healthcare concierge

Send us your enquiry

A concierge service for UK private healthcare. We match you with the best vetted clinics and consultants in our network - they then contact you directly.

So we can match you to the right clinician close to you.

We reply to every enquiry within 24 hours (Mon–Fri). Confidential - your details are never shared outside our vetted consultant network.