Hemodialysis Vascular Access Morbidity 1 Harold

Complications associated with hemodialysis vascular access represent one ofthe most important sources of morbidity among ESRD patients in the United States today. In this study, new data on the magnitude and growth of vascular access-related hospitalization in the United States is presented, demonstrating that the costs of this morbidity will soon exceed $1 billion per yr. This study also reviews published literature on the morbidity associated specifically with native arteriovenous fistulae, polytetrafluoroethylene bridge grafts, and permanent central venous catheters. Next, new information on the changing palterns of vascular access type in the United States is presented, demonstrating the continuing evolution of medical practice away from the use of arteriovenous fistulae in favor of more reliance on synthetic bridge grafts. Based on these data, a discussion is provided of the tradeoffs among the most commonly available modalities of vascular access today. Although radial arteriovenous fistulae continue to represent the optimal access modality, the appropriate roles for brachial arteriovenous fistulae, synthetic bridge grafts, and central venous catheters are less certain because of madequate data on the long-term function of the first and the high rates of complications associated with the latter two. To reduce vascular access-related morbidity, strategies must be developed not only to prevent and detect appropriately early synthetic vascular access dysfunction, but to better identify the patients 1 ReceIved June 2, 1995. Accepted January 3, 1996. 2 Correspondence to Dr. H.!. Feldman, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, 720 Blockley Hall, 423 ServIce Drive, Philadelphia, PA 19104.6021. 104&667310704.0523$03.00/0 Journal of the American Society of Nephrology Copyright C 1996 by the American Society of Nephrology clinical option.