Vascular Access in the Hemodialysis Patient – Personal Experience and Review of the Literature

There is consensus that arteriovenous (AV) fistulae represent the best choice for initial vascular access in patients suffering from chronic renal insufficiency (CRI) or end‐stage renal disease (ESRD) approaching the need of initiating hemodialysis therapy.
However, this is a challenging task in the rapidly growing population of diabetic, aged, and hypertensive patients. The preexisting damage of the vascular anatomy and the high cardiovascular comorbidity hinder construction of a well functioning arteriovenous fistula. Late referrals to the nephrologist delay access surgery and increase the use of temporary and cuffed tunneled catheters with all their potential risks.
Nevertheless, various strategies and tools exist to overcome these problems. Early referral results in venous preservation and early selection of side, site, and type of initial vascular access. Ultrasound findings are essential components of preoperative investigations. Special attention should be paid to the quality of the arteries at each section along the forearm, the elbow region, and the upper arm. Dedicated, meticulous surgery is mandatory. Fistula monitoring and elective revision of the failing AV fistula will result in increasing longevity of the blood access, and will reduce morbidity and costs.