Re: ‘Preferred Strategy for Hemodialysis Access Creation in Elderly Patients’

Abstract

We praise Tordoir et al. for their comprehensive review of the available evidence for vascular access in the elderly. 1 The recommendation of an early cannulation arteriovenous graft (AVG) as a first access contradicts all published vascular access guidelines and challenges the "one-size-fitsall" approach to vascular access.Most published outcomes of arteriovenous fistulae (AVFs) are poor, with high primary failure and moderate patency rates. 2 Therefore, the concept of an autologous AVF being the best form of vascular access is only valid if we assume all AVFs work well.A nonmaturing AVF results in extended catheter use, with its added morbidity and mortality burden. As the dialysis population ages the dogmatic approach recommended by the guidelines must be challenged and emphasis placed on a tailored approach to vascular access. 3 Exhausting vascular access through loss of venous capital is unlikely in elderly patients, and the main priority is to achieve a functional vascular access promptly.However, age alone should not be a contraindication to AVF creation. Many patients aged >65 years are fully active and may have a lower "physiological age". Transplantation listing is based more on this concept than prescriptive age, with positive results. The details of the vignette are lacking and while in these patients an AVG may be the best option, the selective use of autologous AVFs may give superior longer term outcomes with less intervention required. REFERENCES1 Tordoir JH, Bode AS, Van Loon MM. Preferred strategy for hemodialysis access creation in elderly patients. Eur J Vasc Endovasc Surg 2015;49:738e43. 2 Rooijens PP, Tordoir JH, Stijnen T, Burgmans JP, Smet de AA, Yo TI. Radiocephalic wrist arteriovenous fistula for hemodialysis: metaanalysis indicates a high primary failure rate. Eur J Vasc Endovasc Surg 2004;28:583e9. 3 McGrogan D, Field M, Inston N. Survival following arteriovenous fistula formation: are grafts indicated in the elderly? J Vasc Access 2014;15:548.