The optimal initial choice for permanent arteriovenous hemodialysis access

The role of prosthetic AV hemodialysis accesses (AV grafts) in the current era of the Kidney Disease Outcome Quality Initiative and the Fistula First Breakthrough Initiative remains unresolved. As a direct result of these initiatives, a tremendous amount of pressure has been placed on access surgeons to create autogenous AV accesses (AV fistulas), with a national target rate of 66% (prevalence). Indeed, the prevalence of AV fistulas and, perhaps more importantly, the prevalence of central venous dialysis catheters, have become markers for qualitydor lack thereof in the cases of the cathetersdamong dialysis units. It is unclear whether this AV fistula target is realistic or appropriate, and the anecdotal impression has been that the increased emphasis on AV fistulas has inadvertently resulted in an increased failure-to-mature rate and a prolonged dependence on dialysis catheters. These concerns are underscored by the 61% AV fistula failure-to-mature rate reported by the Dialysis Access Consortium from their National Institution of Health, randomized, controlled trial examining the role of clopidogrel.1 The data largely support the superiority of AV fistulas over AV grafts in terms of almost every outcome measure, including patency, morbidity, mortality, and cost. However, the choice of permanent access configurations may not be quite as clearcut or black-and-white as the initiatives suggest. As Dr Wilson and colleagues point out, appropriate comparison of the patency rates mandates inclusion of all accesses that fail to mature, not just those that are successfully cannulated. Accurate patency assessment also mandates comparing comparable patient cohorts, including those deemed high risk for failure after both AV fistula and graft creation, including elderly patients, diabetic patients, women, and amputees. Similarly, the appropriate comparison of the infectious complication rates likely mandates including the catheter-related infections incurred during the fistula maturation period that frequently extends up to 6 months, again potentially diluting or reducing the perceived benefit of AV fistulas. Lastly, AV grafts have several relative advantages over AV fistulas, including an essentially unlimited supply, a shorter maturation period, increased surface area for cannulation, and greater ease of cannulation. The debate about the role of AV grafts relative to AV fistulas may be somewhat artificial or moot, as suggested by both Drs Jennings and Wilson. AV fistulas and grafts should be viewed as alternative options for providing effective, long-term hemodialysis. A mature AV fistula is the ideal choice for most patients and, fortunately, an AV fistula can usually be created or successfully achieved in most patients, as emphasized in the debate. However, AV grafts are a very acceptable alternative that may be more appropriate for certain subsets of patients. The current challenge is to select the most appropriate access type or configuration for a specific patient to ensure a functional access while minimizing morbidity. It is the hope that the results of the Hemodialysis Fistula Maturation study, a prospective National Institutes of Health-funded observation study of fistula maturation, will help refine the clinical decision making for dialysis access, complementing the adverse findings from its predecessor, the Dialysis Access Consortium. However, it is important to emphasize that maintaining permanent hemodialysis access is a difficult problem that requires committed providers and a lifelong plan. Copyright © 2013 by the Society for Vascular Surgery.