title: Preferred strategy for hemodialysis access creation in elderly patients.
abstract: BACKGROUND
  Adequate functioning vascular access is the key to successful hemodialysis. The use of an autologous arteriovenous fistula (AVF) is advised because of good long-term patency and a low incidence of complications. However, the number of patients with AVFs is declining because of the change in the demography of the dialysis population, with increasing numbers of very old patients with multiple comorbidities.
  
  
  METHODS
  In this vignette an elderly patient is described with calcified distal arteries and a small cephalic vein who is referred at a late stage for access creation. The results and performance of different types of vascular access (AVF; arteriovenous graft; central vein catheter), in relation to late referral and patient demographics, are described. In addition, patient morbidity and mortality versus the type of access are discussed.
  
  
  CONCLUSIONS
  The patient described in this vignette appears to be unsuitable for the creation of a forearm AVF because of calcified distal arteries and a small cephalic vein. The risk of non-maturing autologous AVFs is high in elderly patients and this observation might justify the use of early stick grafts. High risk patients may benefit from permanent central vein catheters.
authors.affiliation: Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands. Electronic address: j.tordoir@mumc.nl.
authors.forename: J H M
authors.initials: JHM
authors.lastname: Tordoir
authors.affiliation: Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.
authors.forename: A S
authors.initials: AS
authors.lastname: Bode
authors.affiliation: Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.
authors.forename: M M
authors.initials: MM
authors.lastname: van Loon
mesh_terms: D000367:Age Factors; D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects / Q000401:mortality; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D002405:Catheterization, Central Venous / Q000009:adverse effects / Q000401:mortality; D015897:Comorbidity; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D008297:Male; D018579:Patient Selection; D006435:Renal Dialysis / Q000009:adverse effects / Q000401:mortality; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D034941:Upper Extremity / Q000098:blood supply*; D061205:Vascular Calcification / Q000150:complications* / Q000175:diagnosis
keywords: Arteriovenous fistula; Arteriovenous graft; Central vein catheter; Elderly patients; Hemodialysis; Vascular access