title: Vascular access for hemodialysis: current perspectives.
abstract: A well-functioning vascular access (VA) is a mainstay to perform an efficient hemodialysis (HD) procedure. There are three main types of access: native arteriovenous fistula (AVF), arteriovenous graft, and central venous catheter (CVC). AVF, described by Brescia and Cimino, remains the first choice for chronic HD. It is the best access for longevity and has the lowest association with morbidity and mortality, and for this reason AVF use is strongly recommended by guidelines from different countries. Once autogenous options have been exhausted, prosthetic fistulae become the second option of maintenance HD access alternatives. CVCs have become an important adjunct in maintaining patients on HD. The preferable locations for insertion are the internal jugular and femoral veins. The subclavian vein is considered the third choice because of the high risk of thrombosis. Complications associated with CVC insertion range from 5% to 19%. Since an increasing number of patients have implanted pacemakers and defibrillators, usually inserted via the subclavian vein and superior vena cava into the right heart, a careful assessment of risk and benefits should be taken. Infection is responsible for the removal of about 30%-60% of HD CVCs, and hospitalization rates are higher among patients with CVCs than among AVF ones. Proper VA maintenance requires integration of different professionals to create a VA team. This team should include a nephrologist, radiologist, vascular surgeon, infectious disease consultant, and members of the dialysis staff. They should provide their experience in order to give the best options to uremic patients and the best care for their VA.
authors.affiliation: Department of Clinical and Experimental Medicine, Unit of Nephrology, University of Messina, Italy.
authors.forename: Domenico
authors.initials: D
authors.lastname: Santoro
authors.affiliation: Unit of Vascular Surgery, University of Messina, Italy.
authors.forename: Filippo
authors.initials: F
authors.lastname: Benedetto
authors.affiliation: Unit of Infectious Disease, University of Messina, Italy.
authors.forename: Placido
authors.initials: P
authors.lastname: Mondello
authors.affiliation: Unit of Vascular Surgery, University of Messina, Italy.
authors.forename: Narayana
authors.initials: N
authors.lastname: Pipitò
authors.affiliation: Unit of Vascular Surgery, University of Messina, Italy.
authors.forename: David
authors.initials: D
authors.lastname: Barillà
authors.affiliation: Unit of Vascular Surgery, University of Messina, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Spinelli
authors.affiliation: Department of Clinical and Experimental Medicine, Unit of Nephrology, University of Messina, Italy.
authors.forename: Carlo Alberto
authors.initials: CA
authors.lastname: Ricciardi
authors.affiliation: Department of Clinical and Experimental Medicine, Unit of Nephrology, University of Messina, Italy.
authors.forename: Valeria
authors.initials: V
authors.lastname: Cernaro
authors.affiliation: Department of Clinical and Experimental Medicine, Unit of Nephrology, University of Messina, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Buemi
keywords: arteriovenous fistula; central venous catheter; infection; prosthetic grafts