Vascular Access

Abstract

The prevalence of chronic kidney disease (CKD) in the USA is nearly 15%; Medicare spends nearly $114 billion on patients with CKD and end stage renal disease (ESRD) with a large proportion of this money going to access related complications. The National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-KDOQI) publishes clinical practice guidelines for vascular access with the aim to improve outcomes in dialysis. The main initiatives are to increase autogenous access use and protect existing accesses. The Centers for Medicare and Medicaid services Fistula First Breakthrough Initiative (FFBI) (2005) pushes for the use of autogenous fistulas in patients and through these initiatives have been making strides toward reducing catheter use and catheter related complications. However, the prevalence of autogenous access has plateaued at around 60%, and as many as 80% of new dialysis patients are still initiating dialysis with a catheter. Most recently the initiative changed to Fistula First Catheter Last (FFCL) noting that autogenous access is not feasible in all patients and pushing for prosthetic graft use over catheters. Although vascular surgeons are not the first to encounter dialysis patients, we play a key role in eliminating barriers to reliable access including facilitating entry into vascular clinics, establishing reliable access, and remaining vigilant to potentially failing accesses. The SVS published clinical practice guidelines in 2008 for the surgical placement and maintenance of hemodialysis access encompassing timing of referral, operative strategies, monitoring and surveillance, and management of malfunctioning and failed access. In this chapter we review the evaluation of an access patient, selection of location and type of access as well as some common pitfalls and complications.