Current Management of Vascular Access

Abstract

Optimizing vascular access outcomes remains an ongoing challenge for clinical nephrologists. All other things being equal, fistulas are preferred over grafts, and grafts are preferred over catheters. Mature fistulas have better longevity and require fewer interventions, as compared with mature grafts. The major hurdle to increasing fistula use is the high rate of failure to mature of newly created fistulas. There is a desperate need for enhanced understanding of the mechanisms of failure to mature and the optimal type and timing of interventions to promote maturity. Grafts are prone to frequent stenosis and thrombosis. Surveillance for graft stenosis with preemptive angioplasty may reduce graft thrombosis, but recent randomized clinical trials have questioned the efficacy of this approach. Graft stenosis results from aggressive neointimal hyperplasia, and pharmacologic approaches to slowing this process are being investigated in clinical trials. Catheters are prone to frequent thrombosis and infection. The optimal management of catheter-related bacteremia is a subject of ongoing debate. Prophylaxis of catheter-related bacteremia continues to generate important clinical research. Close collaboration among nephrologists, surgeons, radiologists, and the dialysis staff is required to optimize vascular access outcomes and can be expedited by having a dedicated access coordinator to streamline the process. The goal of this review is to provide an update on the current status of vascular access management.

Long-term Outcomes of Arteriovenous Thigh Grafts in Hemodialysis Patients

“…Once this occurs, continued hemodialysis requires a choice between placing an arteriovenous graft in the thigh or long-term dependence on tunneled hemodialysis catheters (1). All grafts are prone to recurrent stenosis and thrombosis, which can lead to permanent access failure (2), but there are few publications on the outcomes and complication of thigh grafts. Most published studies reported the outcomes of relatively few thigh grafts, with inconsistent definitions of graft outcomes (3)(4)(5)(6)(7)(8)(9)(10)(11).…”

Does the Heparin Lock Concentration Affect Hemodialysis Catheter Patency?

“…Anticoagulant solutions are instilled into both catheter lumens after each dialysis session in an effort to prevent interdialytic catheter thrombosis (1). Heparin is the predominant anticoagulant lock solution used in U.S. hemodialysis units.…”

Predictive Parameters of Arteriovenous Fistula Functional Maturation in a Population of Patients with End-stage Renal Disease

“…Mortality rate has been shown to be significantly higher in those who dialyse first by means of tunnelled catheters, and at the same time, they are at increased risk of failure of subsequent AVF [7,9,10]. Arteriovenous grafts tend to have better primary patency rates compared to AVF [6,11,12], however AVFs last longer, and with the exception of those fistulas which fail to mature primarily, the cumulative patency (from formation to permanent failure) is superior to grafts; moreover, AVFs-once they fully mature-are less likely to require secondary procedures for vascular access salvage to maintain patency, including angioplasty, stenting or thrombectomy [6,[13][14][15][16]. The 2006 updated NKF-KDOQI Guidelines recommend AVF prevalence of 65% for patients undergoing HD [17].…”