Based on the data obtained from this equation, the highest number of optimal dialysis onsets with functioning, mature vascular access was achieved when AVF had been placed in patients with KFRE of >20% annually, or 40% over 2 years. This useful prediction tool may help reduce the number of chronic renal disease patients who died with an unused AVF, thus minimizing the treatment costs and patient discomfort.
On the other hand, the AV access should be promptly created when needed, with the aim of reducing the number of patients who start dialysis with a central venous catheter (CVC).
Something old, something new
The 2006 KDOQI guidelines on vascular accesses for hemodialysis focused on promoting AVFs as the preferred vascular access in all ESRD patients (4). Current evidence-based recommendations, however, have moved past the well-known Fistula First – Catheter Last doctrine. The latest KDOQI guidelines on vascular accesses underline the importance of an individual approach to each patient when planning his/her treatment. The key concept, as presented in the guidelines, is creating an individual ESRD Life-Plan which should encompass all possible treatment options and related outcomes (5). Thus, the new principle when it comes to planning the vascular access is Right Access in the Right Patient at the Right Time for the Right Reasons (5). Furthermore, the new approach underlines the importance of at least quarterly reviews of vascular access functionality, complications risks, and other access options (5).
There are currently several possible approaches to choosing the optimum renal replacement therapy within the framework of the patients’ life plan, and then the right vascular access if hemodialysis is the treatment of choice. As for the permanent vascular accesses, the AVF remains the ultimate goal, but new creation strategies, namely the percutaneous approach, have been introduced into practice. Other options are AV grafts, either early or late cannulation ones, and tunneled central venous catheters. The previous doctrine to avoid long-term central venous catheter at any cost has been abandoned in the latest guidelines, which suggest that in certain, well-evaluated cases, it is reasonable to use tunneled central venous catheter for the short or long-term duration even as a first choice vascular access (5).
Adequate blood vessel preservation is crucial for creating a well-functioning AVF. Venipuncture and peripheral IV lines can damage the veins and jeopardize future AVF construction and function. Thus, preservation of forearm veins should start well before the patient needs access. The preferred and most often used superficial vein in the upper extremity for AVF creation is the cephalic vein. Radiocephalic AVFs are the first, and brachiocephalic AVF at the elbow the second choice for AVF creation (6). The other superficial veins in the forearm, the basilica vein on the ulnar side, and the median basilica vein near the elbow are occasionally used. The brachial veins in the upper arm are only used for vascular access creation as the last resort. Synthetic AV grafts are utilized for dialysis access creation in cases when the native vessels are not suitable for creating an AVF (6). The commonly used configurations include the forearm loop, upper arm straight and thigh loop grafts.
New development in the field of vascular access creation
The main obstacles associated with AVFs creation and use are protracted wait time for creation, poor maturation, and surgical dysfunction that can result in significant patient morbidity and preclude the optimum dialysis (7). The recent approval of minimally invasive endovascular devices designed to enable the percutaneous approach to the creation of AVFs may potentially reduce the wait and maturation time, provide more anatomical options for AVF creation and avoid surgery and related complications thus providing patients with more choice and better quality of life (7). The currently available percutaneous techniques for creating AVFs are presented in Figure 2. Ellipsys is an ultrasound-guided, single catheter device, while the WavelinQ, on the other hand, is a dual catheter device that is placed under fluoroscopy.