Vascular Access for Hemodialysis

A progressive rise in the number of patients accepted for renal replacement therapy has been reported world wide [1]. Permanent vascular access (VA) is the life-line for the majority of these patients, when hemodialysis is the treatment of choice. Thus, the successful creation of permanent vascular access and the appropriate management to decrease the complications is mandatory. A well functional access is also vital in order to deliver adequate hemodialysis therapy in end-stage renal disease (ESRD) patients. Unfortunately, despite the advances in hemodialysis technology, the introduction of the polytetrafluoroethylene (PTFE) graft and the cuffed double lumen silicone catheter were the only changes in the field of vascular access in the last years. However the cost of vascular access related care was found to be more than fivefold higher for patients with arteriovenous graft (AVG) compared with patients with a functional arteriovenous fistula (AVF) [2]. It seems that the native arteriovenous fistula that Brescia and Cimino described in 1966, still remains the first choice VA [3]. Thereafter, vascular access still remains the “Achilles’ heel” of the procedure [4] and hemodialysis vascular access dysfunction is one of the most important causes of morbidity in this population [5]. It has been estimated that vascular access dysfunction is responsible for 20% of all hospitalizations; the annual cost of placing and looking after dialysis vascular access in the United States exceeds 1 billion dollars per year [6, 7]. Nowadays, three types of permanent vascular access are used: arteriovenous fistula (AVF), arteriovenous grafts (AVG) and cuffed central venous catheters. They all have to be able to provide enough blood flow in order to deliver adequate hemodialysis, have a long use-life and low rate of complications. The native forearm arteriovenous fistulas (AVF) have the longest survival and require the fewest interventions. For this reason the forearm AV is the first choice, followed by the upper-arm AVF, the arteriovenous graft (AVG) and the cuffed central venous catheter as a final step [8-10].