Current topics on vascular access for hemodialysis.
Vascular access remains the lifeline for end-stage renal failure patients, which have been treated by chronic intermittent hemodialysis. Due to the steady increase in the number of patients with difficulties to create access, in particular in elderly with various comorbidities, the need for more insight and regulations have evolved into the publications of the American and European guidelines. From the latter it may be obvious that an adequate preoperative assessment followed by the creation of autogenous arteriovenous fistulas (AVFs) is far better and preferred to the implantation of grafts. Vascular access maintenance by monitoring and elective percutanuous or surgical revision is of utmost importance to keep the access site functional. Despite up-to-date measures for vascular access maintenance, various complications may treaten not only the access site but also quality and expectance of life. Thrombotic occlusion remains a major event, leading to permanent failure in 10% of AVFs and 20% of grafts each year. Interventional (percutaneous transluminal angioplasty and/or stent implantation) or surgical revision of thrombosed accesses have similar outcomes with a high rate of reinterventions. The elderly diabetic population with peripheral arteriosclerotic obstructive disease is in particular prone to angio-access induced handischemia. When not timely and properly treated this may lead to minor or major amputation, further hampering quality of life. Also, the enormous application in the past 2 decades of acute central venous lines has lead to a significant increase of central venous obstruction with concomittent morbidity and problems creating vascular access in the upper extremities. Radiological intervention in these cases is a primary option, leaving surgical reconstruction as a second best method. It may be obvious that creation and maintenance of hemodialysis vascular access has become an important and time-consuming speciality. Only an up-to-date multidisciplinary management with involvement of nurses, nephrologists, interventionalists and surgeons, will lead to the desired outcome.
Department of Surgery, University Hospital Maastricht, Maastricht, The Netherlands. j.tordoir@surgery.azm.nl
J H M
JH
Tordoir
F M
FM
Van Der Sande
M W
MW
De Haan
D001132:Arm; D001166:Arteriovenous Shunt, Surgical; D002408:Catheters, Indwelling / Q000009:adverse effects; D005500:Follow-Up Studies; D006801:Humans; D007511:Ischemia / Q000209:etiology / Q000628:therapy; D011300:Preoperative Care; D006435:Renal Dialysis / Q000379:methods*; D013927:Thrombosis / Q000209:etiology / Q000628:therapy