Haemodialysis Access

Arteriovenous Fistulas and Synthetic Arteriovenous Grafts

At the end of 2009, there were 571,414 patients being treated for end-stage renal disease in the United States with 116,395 new cases in that year ; approximately 65% of these patients received haemodialysis. Complications associated with vascular access procedures are a major cause of morbidity and increasing healthcare costs in patients undergoing haemodialysis. For patients with end-stage real disease (ESRD) requiring haemodialysis, there are two options for vascular access, either the surgical creation of an arteriovenous fistula (AVF) or implantation of a synthetic arteriovenous graft (graft). Due to the lower rates of infection and thrombosis, mature AVFs are the preferred access when possible. Preoperative ultrasound evaluation of the upper extremity arteries and veins has been shown by several studies to increase the success rate of AVF creation by influencing surgical planning. While sonographic postoperative haemodialysis access evaluation may be beneficial in assessing AVF maturation, the role of postoperative ultrasound monitoring for early detection of access pathology allowing prompt intervention to increase the longevity of an access is still evolving.

When clinically feasible and anatomically possible, the surgical creation of an AVF is preferred over a graft. Access placement in the non-dominant arm allows activities of daily living to continue as the non-dominant arm recovers; however, it is preferential to place a dominant arm AVF as opposed to a non-dominant arm graft in most patients. Potential haemodialysis access sites in decreasing order of preference are as follows: (1) forearm AVF (radiocephalic AVF or transposed forearm basilic vein to radial artery AVF); (2) upper arm brachiocephalic AVF or transposed brachiobasilic AVF; (3) forearm loop graft; (4) upper arm straight graft (brachial artery to upper basilic/axillary vein); (5) upper arm axillary artery to axillary vein loop graft; and (6) thigh graft. Other less common access configurations may also be utilised based on surgical experience. Cephalic vein use is preferred over a basilic vein transposition for fistula formation because the cephalic vein procedure involves less dissection and venous handling.