Home > Journals > Minerva Urology and Nephrology > Past Issues > Minerva Urologica e Nefrologica 2004 September;56(3) > Minerva Urologica e Nefrologica 2004 September;56(3):223-35



To subscribe
Submit an article
Recommend to your librarian





Minerva Urologica e Nefrologica 2004 September;56(3):223-35


language: English

Current topics on vascular access for hemodialysis

Tordoir J. H. M. 1, Van Der Sande F. M. 2, De Haan M. W. 3

1 Department of Surgery University Hospital Maastricht Maastricht, The Netherlands 2 Department of Nephrology University Hospital Maastricht Maastricht, The Netherlands 3 Department of Radiology University Hospital Maastricht Maastricht, The Netherlands


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.

top of page