Standard of care for the treatment of hemodialysis access infection involves prompt hospitalization and systemic antibiotics followed by surgical excision of the graft and open wound packing. The treatment is tailored based on the type of access. Surgical decision-making involves the considerations for access salvage, vascular reconstruction, and wound management. Salvage may be attempted if only local signs of infection are seen without skin breakdown or bacteremia. This strategy allows for continued dialysis access and avoids additional catheter days. Early graft infection (<30 days) should be treated by complete graft excision and placement of new access elsewhere [22].

In prosthetic AVG infections, salvage may be attempted with only localized erythema or a focal sinus track. In cases of midgraft infection, the uninvolved segments of the prosthetic material are exposed proximally and distally, while the infected segment is covered with an impermeable dressing. A new segment of prosthetic material is tunneled through clean tissue planes, anastomosis completed, and incisions are closed. The infected portion of the segment is then excised through a separate incision followed by local care for the infected wound. Various authors have reported an access salvage rates ranging from 74 % to upwards of 90 % [22–24]. With anastomotic infections, a complete excision of prosthetic material is usually required along with patch repair of the artery. Partial graft excision while leaving a 2–3 mm cuff of well-incorporated prosthetic on the underlying artery to be used for a new tunneled graft is a technique for access salvage. Ryan et al. reported their experience treating 51 infected PTFE AVGs in 45 patients employing 13 successful total graft excisions, 15 subtotal graft excisions with graft cuffs left, and 23 partial graft excisions leaving a portion of usable graft. Of these 23, 6 patients ultimately required total graft excision due to nonhealing wounds with an overall success rate of 74 %. However, this approach has high reinfection rates in another study by Walz et al. [23, 25]. Brachial artery ligation has been reported in critically ill patients with grossly infected prosthetic AVGs with ischemic complications in one-third of the patients in a series by Schanzer et al. [26, 27]. Replacement of the prosthetic AVG with cryopreserved femoral vein or femoral artery has been described by Matsuura et al. with 1-year primary and secondary patency rates of 42 and 68 % and only 2.3 % recurrent infection rate [28]. A thrombosed AVG can serve as a nidus for infection. In presence of systemic signs of infection, the graft excision may be performed once the thrombosed AVG is proved to be a source of infection. Rarely, a thrombosed AVG with no obvious sign of infection may be removed in a septic patient with no otherwise identified source of sepsis.

Infections in hemodialysis access can be life-threatening but are often identified early and treated with excision and antibiotics. The extent of excision versus salvage of the access, the management of the brachial artery anastomosis, and the timing and conduit used for future access should be managed on a case-by-case basis. If temporary access is required, the patients are at further infection risk from the tunneled catheters and should be converted to permanent access as soon as it is feasible. The best management for AVG infection is prevention with good hygiene, fewer hospitalizations, good nutrition, and minimizing interventions.