Strategies for Hemodialysis Access: Where to Start,Where to Go Next

Complications of vascular access are the most common cause of hospitalization for patients with end stage renal disease. Physicians involved in the placement and maintenance of hemodialysis access must have a long-term strategy for sequential placement of autogenous fistulas and synthetic grafts to preserve limited access sites. Although many principles involving hemodialysis access surgery are widely accepted, significant controversies exist regarding optimal access strategies. Autogenous access is generally preferred over prosthetic grafts. The nondominant upper extremity is the preferred site of initial access. Cuffed catheters are discouraged for long-term vascular access unless no other options are present. Recent advances in forearm, upper arm, and femoral venous transpositions have facilitated the performance of increased numbers of autogenous access procedures. Nevertheless, substantial numbers of patients on chronic hemodialysis require prosthetic arteriovenous grafts. Although the Kidney Disease Outcomes Quality Initiative of the National Kidney Foundation has provided general guidelines for access creation, considerable controversy remains regarding the optimal choice of prosthetic graft material and configuration. We present a strategy for the sequential placement of arteriovenous fistulas, venous transpositions, and arteriovenous grafts to guide the surgeon in the management of these often challenging patients.