Management Strategies in Hemodialysis Vascular Access
Since the introduction of the AV fistula and the use of interposition graft little improvement has been made in the vascular access field. Still, vascular access related complications, are one of the most important reasons for patient hospitalization, morbidity and even mortality (1,2). Interestingly, the costs of vascular access related care was found to be more than fivefold higher for patients with AVG compared with patients with a functioning AVF (3). In an attempt to improve overall patency rates and reduce access related costs, the NFK-DOQI committee currently recommends that in any dialysis center the majority of new dialysis patients should have a primary AVF constructed (4,5). Unfortunately, creation of an AVF is not always possible as a consequence of prior vascular access surgery, insufficient caliber of forearm vessels or sclerosis caused by prior venipunctures. Although less thrombotic and infectious complications occur in AVF, the AVF is not ideal, i.e. 100% successful. Adequate maturation of AVF, i.e. sufficient dilatation and arterialization, fails in up to 30% of all newly created fistulae, resulting in delayed initiation of dialysis treatment or placement of temporary central venous dialysis catheters, and related morbidity (6-10). Optimalization of patient selection could improve AVF patency rates and access related morbidity. Considering the increasing age of hemodialysis patients, prolongation of the dialysis therapy, and the worldwide increase of the number of patients requiring hemodialysis, the number of AV grafts will probably increase rather than decrease. As a consequence, vascular access complications, particularly thrombosis, will continue to challenge vascular access care in the future.