Vascular access today

Abstract

The number of patients with chronic kidney disease requiring renal replacement therapy has increased worldwide. The most common replacement therapy is hemodialysis (HD). Vascular access (VA) has a key role for successful treatment. Despite the advances that have taken place in the field of the HD procedure, few things have changed with regards to VA in recent years. Arteriovenous fistula (AVF), polytetrafluoroethylene graft and the cuffed double lumen silicone catheter are the most common used for VA. In the long term, a number of complications may present and more than one VA is needed during the HD life. The most common complications for all of VA types are thrombosis, bleeding and infection, the most common cause of morbidity in these patients. It has been estimated that VA dysfunction is responsible for 20% of all hospitalizations. The annual cost of placing and looking after dialysis VA in the United States exceeds 1 billion dollars per year. A good functional access is also vital in order to deliver adequate HD therapy. It seems that the native AVF that Brescia and Cimino described in 1966 still remains the first choice for VA. The native forearm AVFs have the longest survival and require the fewest interventions. For this reason, the forearm AVF is the first choice, followed by the upper-arm AVF, the arteriovenous graft and the cuffed central venous catheter is the final choice. In conclusion, VA remains the most important issue for patients on HD and despite the technical improvements, a number of problems and complications have to be resolved.

Risk factors for catheter-related infections in patients on hemodialysis

“…The number of patients at the end-stage of renal disease in the need of renal replacement therapy is rising in Europe and the world 1 . At the end of 2013, 5,775 patients were on renal replacement therapy, and the majority of them was on hemodialysis -4,480 2 .…”

“…The quality of life and survival expectancy of those patients depend on the duration of functional vascular approaches (VA) 3 . Since the artery-vein fistula (AVF), which was depicted back in 1966 by Braescia and Cimino, has the longest survival rate and the least complication frequency, it should, whenever it is possible, be the first choice for VA 1 . Hemodialysis catheters are used for quick establishing of an adequate VA, when urgent hemodialysis is indicated in time of maturation of AVF and in patients in whom all other VA have been exhausted 1,4 .…”

“…Since the artery-vein fistula (AVF), which was depicted back in 1966 by Braescia and Cimino, has the longest survival rate and the least complication frequency, it should, whenever it is possible, be the first choice for VA 1 . Hemodialysis catheters are used for quick establishing of an adequate VA, when urgent hemodialysis is indicated in time of maturation of AVF and in patients in whom all other VA have been exhausted 1,4 . Despite the priorities of AVF, nearly 80% of those patients start treatment with the dialysis catheters 3 .…”

On Postoperative Day Balloon Angioplasty for Salvage of Newly-Placed, Flow-Limiting Native Arteriovenous Fistula

“…Native arteriovenous fistula (AVF) is recommended as a first AV access in end stage renal disease paitents who need hemodialysis [ 1 ]. Many reports have shown variable postoperative results [ 2 , 3 ], and early failure rates are considerable in some reports [ 4 , 5 ]. Postoperative palpable thrill suggests successful native AVF creation [ 6 ] and practitioners wait several weeks for maturation to occur.…”

Bedside Tunneled Dialysis Catheter Removal-A Lesson Learned From Nephrology Trainees

“…These "semipermanent" catheters have the advantage of retaining themselves in the subcutaneous tissue by a Dacron "cuff" eliciting soft tissue growth and scarring and have lesser propensity to suffer from exit site infections (13). Nonetheless, they represent an inferior access modality compared with conventional AV fistulas and grafts (14)(15)(16)(17)(18) and their utilization is associated with increased mortality (19)(20)(21). The current literature on TDCs is focused around circumstances of placement (22)(23)(24), malfunction and maintenance of catheter patency (25)(26)(27), as well as prevention of infections (28)(29)(30)(31).…”