EBPG on Vascular Access

Guideline 1.1. An early plan for venous preservation should be a substantial part of pre-dialysis care and education in any chronic kidney disease (CKD) patient regardless the choice of treatment modality (Evidence level IV). Guideline 1.2. Every chronic renal failure patient, who have opted for haemodialysis, should start dialysis with a functioning vascular access (Evidence level III). Guideline 1.3. Potential chronic haemodialysis (HD) patients should be ideally referred to the nephrologist and/or surgeon for preparing vascular access when they reach the stage 4 of their CKD (glomerular filtration rate <30 ml/min/1.73 m 2 ) or earlier in case of rapidly progressive nephropathy or specific clinical conditions such as diabetes or severe peripheral vascular disease (Evidence level III). Early referral of CKD patients to the nephrologist and/or vascular surgeon is strongly recommended. This is to start a policy to preserve access sites and to allow adequate time for planning, creation and maturation of the vascular access. The planning stage involves examination and pre-operative vascular mapping. An autogenous fistula requires at least 6 weeks for maturation before it can be used. Additional time may be required for interventional or surgical revisions to enhance maturation. For these reasons, it is recommended that the fistula is created at least 2–3 months before the earliest likely date for starting haemodialysis. Prosthetic graft AVFs do not need a maturation period and can be cannulated 2–3 weeks after implantation. However, prosthetic graft AVFs are not recommended as primary vascular access. This approach is recommended to minimize the use of catheters and to reduce catheter-related morbidity and need for hospitalization. Early referral to the nephrologist is also required for psychological preparation for dialysis, discussion of all options for dialysis modality, interventions to delay progression of renal damage and to correct the hypertension, anaemia and metabolic effects of renal failure [1–5]. Streamlining of early patient referral and organization of predialysis care are major subjects for research. A policy of venous preservation should be educated and implemented. European Best Practice Guidelines Expert Group on Hemodialysis, European Renal Association. Section I. Measurement of renal function, when to refer and when to start dialysis. Nephrol Dial Transplant 2002; 17[Suppl 7]: 7–15 Ravani P, Marcelli D, Malberti F. Vascular access surgery managed by renal physicians: the choice of native arteriovenous fistulas for hemodialysis. Am J Kidney Dis 2002; 40: 1264–1276 Allon M, Ornt DB, Schwab SJ et al . Factors associated with the prevalence of arteriovenous fistulas in hemodialysis patients in the HEMO study. Hemodialysis (HEMO) Study Group. Kidney Int 2000; 58: 2178–2185 Jungers P, Massy ZA, Nguyen-Khoa T et al . Longer duration of predialysis nephrological care is associated with improved long-term survival of dialysis patients. Nephrol Dial Transplant 2001; 16: 2357–2364 Ortega T, Ortega F, Diaz-Corte C, Rebollo P, Ma Baltar J, Alvarez-Grande J. The timely construction of arteriovenous fistulae: a key to reducing morbidity and mortality and to improving cost management. Nephrol Dial Transplant 2005; 20: 598–603 Guideline 2.1. Clinical evaluation and non-invasive ultrasonography of upper extremity arteries and veins should be performed before vascular access creation (Evidence level II). Guideline 2.2. Central vein imaging is indicated in patients with a history of previous central vein catheters (Evidence level IV). There is a significant failure rate for autogenous arteriovenous fistulae (AVFs), estimated at 0.2 events per patient/year. For graft AVF, this increases to 0.8–1.0 events per patient/year. In a recent meta-analysis, the primary failure rate for autogenous wrist AVF was 15.3%. Primary and secondary 1-year patency rates were 62.5 and 66.0% [1]. Nowadays, the chronic dialysis population is becoming elderly and is increasingly likely to have diabetes, peripheral arterial obstructive disease (PAOD) or coronary artery disease. Many of these patients have poor vessels for construction of autogenous fistulae and this may be the major reason for the high primary failure and moderate long-term patency. Careful selection of suitable vessels based on objective evaluation, is required for successful creation of a functioning AVF. Physical examination is used for pre-operative assessment and access planning. This includes assessment of the distal arterial pulse and the presence, and of the and upper Physical examination may be in patients and on the of the assessment with ultrasonography the of creation and the of autogenous AVF. In a the primary AVF failure rate was when pre-operative assessment on examination with when ultrasonography was used In the performed by et al . for vascular access creation were based on pre-operative with a artery of and a vein of AVFs were used in patients with arteries or veins and in with vein in the with a of The of creation to the early failure rate to In the fistula rate to were performed in dialysis with their autogenous fistula creation rate in that the maturation rate of AVFs to as the autogenous fistula creation rate to after the of pre-operative This that selection based on at pre-operative imaging are to and arteriovenous access is in patients. AVF rates were in patients with 2 with patients with when pre-operative vein was artery the or of and the for vascular access et al . or failure to maturation in all created in patients with a artery of In successful a artery of in created with with a patency rate in the was in the the patency rates after weeks were The of the artery and pre-operative is However, a significant artery and pre-operative and the of AVF creation of have associated with AVF failure patency rates were in patients with the of the vein at the wrist was or upper veins The vein after of a is of In a of created the vein by vein by in the of fistulae the ) a of the vessels artery and of is for the creation of successful of and/or upper vessels for the creation of successful fistula creation are not for successful creation for successful creation preservation with may enhance the and of arteries and veins for fistula creation may in renal in patients with severe renal not suitable for patients who are preparing for dialysis or for dialysis patients with renal is a to with imaging and planning 2 can also be of of renal with or used for access planning. in a of were and on a with on the of are Central vein imaging can be performed by the for imaging of arterial and venous of significant pre-operative for successful fistula creation and maturation a major for imaging with should be T, wrist arteriovenous fistula for a high primary failure J et al . vein and hemodialysis J 2001; 20: et al . A for use of autogenous hemodialysis access of J Allon vascular before hemodialysis access 2000; Allon M, of on vascular access in hemodialysis patients. Kidney Int 2001; to hemodialysis the of vein mapping. 2002; 16: vascular access in the Am J J, of arteriovenous fistula of dialysis for hemodialysis access. J J, and hemodialysis patients have a prevalence of functioning arteriovenous fistula pre-operative vein mapping. Nephrol 2002; 58: J, Factors associated with early failure of arteriovenous fistulae for haemodialysis access. J pre-operative examination patency rates of Nephrol Dial evaluation of vessels by to construction of arteriovenous fistulas for haemodialysis. Nephrol Dial Allon artery evaluation and with fistula J of the artery is to early primary hemodialysis fistula Nephrol 2001; arteriovenous Am J Kidney Dis 2002; of venous assessment to arteriovenous fistula Nephrol 2002; 58: J. of on the arteries and veins in patients with renal disease. M, et al . extremity with before fistula creation for hemodialysis. Kidney Int 2001; D, A et al . Hemodialysis access fistula assessment with and with in the evaluation of hemodialysis access and the of central veins in patients who are for hemodialysis access. J Nephrol P, A et al . in the of of dialysis and J Guideline The access should to adequate haemodialysis (Evidence level II). Guideline arteriovenous fistulae should be and should be catheters (Evidence level III). Guideline The upper extremity arteriovenous fistula should be the access and should be as distal as (Evidence level III). Guideline maturation should be to allow (Evidence level III). For have in for access creation and the In the of and patients autogenous arteriovenous fistulae in the prosthetic graft the access of choice in of the dialysis graft The reason for this is not patient to be in and this the for access and Practice that rates of diabetes peripheral arterial obstructive disease (PAOD) coronary artery and are in the dialysis population is estimated that AVF 0.2 interventions per with per for prosthetic graft fistulae for access In long-term primary access survival to for AVF and to for graft at and 2 of access and the secondary survival of may to a The patency rate for may be with to at and 2 of et al . that do not the of haemodialysis autogenous arteriovenous patients a period of by was used as a secondary of dialysis The wrist AVF is the for access the it may for with a of revisions and The high early is the major of this access and is by patient diabetes and the of disease. Early failure rates to and long-term patency to at and 2 of The of events per and is a wrist is to poor vessels a the to the the artery and vein may be peripheral vessels are and for the creation of fistulae are indicated at the and AVFs and a high is for dialysis. The of and is and long-term is The major of these AVFs are the of distal may to and in patients with coronary artery disease and/or failure The rate for AVFs should be by pre-operative assessment Guideline and of maturation. by at and after is of successful maturation. AVFs with rates of to in the of the AVF with high on the the of in and of is to the of significant or arterial or evaluation is indicated when is failure of maturation. is indicated for any and when not successful surgical can be The use of vascular for arteriovenous may damage and reduce the to have that patient may have on the choice and of vascular access. may have on in created autogenous in a failure rate with patients However, the of and diabetes have on fistula with failure rates and have of in elderly patients. In the use of in patients to in patients of In and significant were as a for graft use in and patients. In were associated with poor in of primary failure and with a of revisions with fistulae the may do in the et al . patency at 2 and for prosthetic with This can be by the high of to early failure of the fistulae have arteries and veins may do with this may be the reason for maturation and survival rates of vascular access. However, the et al . that arterial and venous were not and and functioning fistulae were created in of the and of the patients. In a of maturation and 1-year patency rates as is that pre-operative selection for the of access of that was associated with use of and a of access revisions In the HEMO Allon et al . and significant for the on fistula In they in the of fistulae used in the dialysis to the a in the of renal and are the for dialysis The of diabetes and may have on the of successful access creation patients have and arteries with and/or distal creation is and the of of the upper and extremity to is significant Guideline Many a the use of prosthetic graft AVF and the prevalence of diabetes in their The of graft is in in graft survival the autogenous fistula creation can be successful in patients with of primary fistula creation with the use of in and patients have were in of primary fistula creation in have by et al . of fistulae were created and of the patients were created in and of patients and AVFs were in Primary access survival was secondary survival was in at 2 of in the events per do not have any on vascular access failure dialysis patients may be a for access et al . in a as for fistula The specific use and access failure was in the study. with and in improved graft and fistula patency referral and starting dialysis treatment with a central venous reduce the of successful autogenous fistula creation and of the vascular access surgery have a on et al . that the of the surgeon was the major for the patency of vascular access and it that this approach may in a of functioning fistulae The of any is for patients with for with and In the mortality rate is for with or central venous with with autogenous AVF. In were in and patients with central venous catheters with with AVF. may and this not in a patient the in patients with vascular access and may be after access in patients with functioning renal autogenous AVF creation is or the fistula may to as a vascular access vein or vein have used for time with moderate vein or are as access with patency and rates Prosthetic are as and patency is at the to to The primary patency rate of prosthetic graft AVFs to and to at and 2 of patency to and to at and 2 with and and is the major for and The of is high the in and of a of that the to and may have with in elderly patients in et al . of graft in patients. that this patient a and early may be with the of central venous the on is as with autogenous and clinical have to the of of graft and graft on graft patency. the of the arterial and/or venous of the graft have a on Clinical the arterial of the not patency rates at the venous However, primary patency with the use of a by the of the with the vein at the However, in clinical this was not The use of or on graft survival In a failure was not in the treatment with However, major in of patients in the with in the In the patients that used such as graft survival In and was with a a on with a of et al . of and on graft and in their the of was A of on AVF and graft patency in a of patients The of not graft patency and have to prosthetic graft AVFs to to at the venous In effects be in patient in graft patency was and the of effects such as not any of on graft patency rates the for extremity vascular access is central venous or vein the of upper extremity AVF. or vein are primary options for AVF with a high on Guideline Clinical and primary by of the are indicated to Prosthetic graft in the a high of and There may be a for central venous catheters as for vascular access. with severe upper extremity or failure may be for for these patients is likely to be poor and the need for vascular access to The for patients with the of autogenous fistulae for vascular the of and the of of et al . Vascular access use in and the the Kidney Int 2002; Hemodialysis vascular access and in the and Practice Study Kidney Int 2002; DB, F, of dialysis access for J Vascular is of of vascular access. Nephrol Dial T, wrist arteriovenous fistula for a high primary failure J of autogenous fistula graft fistula for in hemodialysis. Am J M, fistulas patency rates and of J 2002; the of diabetes on and J 2002; vein for haemodialysis vascular with a Nephrol Dial 2001; 16: of upper arteriovenous fistulas for hemodialysis access. D, et al . vein for arteriovenous Am J vein for dialysis Int Schwab of fistulas to upper and Kidney Int 2001; P, J, of fistula for haemodialysis. J P, Vascular access the vein arteriovenous Am J Kidney Dis of autogenous and upper extremity arteriovenous hemodialysis a J the vascular access for dialysis patients. Kidney Int 2002; F, in hemodialysis patients on of vascular access. J M, C, J. with in construction of arteriovenous fistulas for access. J, Factors associated with early failure of arteriovenous fistulae for haemodialysis access. J P, M, evaluation of failure in autogenous wrist access for haemodialysis. Nephrol Dial J, et al . of native arteriovenous fistulae for hemodialysis by interventional Kidney Int 2000; of for arteriovenous autogenous access for hemodialysis. J 2001; P, J, treatment of early fistula Kidney Int J. with vascular in the creation of arteriovenous fistulae for hemodialysis. Am J and vascular in dialysis Am J 2001; clinical of or for arteriovenous J of and diabetes on rate and primary of created hemodialysis arteriovenous Am J Nephrol J, M, Vascular access for dialysis in the 2002; 20: J, M, Vascular access for haemodialysis of the Renal Nephrol Dial hemodialysis a of vascular access. Vascular access survival and of a of prosthetic autogenous and venous fistulas the Renal and J 2001; of vascular access in the hemodialysis Kidney Int Vascular access in the hemodialysis Am J Kidney Dis of and prosthetic arteriovenous fistulas in elderly patients. J 2000; M, J. are Am J Kidney Dis T, M, F. of vascular access for hemodialysis. Transplant et al . of of vascular access in hemodialysis patients. M, C, A approach to vascular access for hemodialysis and of J of surgery for vascular access in patients haemodialysis. J SJ Schwab et al . Factors associated with the prevalence of arteriovenous fistulas in hemodialysis patients in the HEMO study. Hemodialysis (HEMO) Study Group. Kidney Int 2000; 58: 2178–2185 et al . of artery is associated with early failure of arteriovenous fistula in hemodialysis patients. Am J Kidney Dis vascular a Am J Kidney Dis M, J. Hemodialysis access with vascular patients with and Am J Kidney Dis 2001; et al . and vascular access in haemodialysis a metabolic Nephrol Dial et al . of nephrologist referral and arteriovenous access the Am J Kidney Dis 2001; vascular access in hemodialysis patients. and Practice vascular access failure and the use of specific the and Practice Study Am J Kidney Dis 2002; 40: European Best Practice Guidelines Expert Group on Hemodialysis, European Renal Association. Section I. Measurement of renal function, when to refer and when to start dialysis. Nephrol Dial Transplant 2002; 17[Suppl 7]: 7–15 J, et al . nephrologist referral and vascular access in patients with chronic kidney J 2002; C, P, et al . of on mortality and Am J Kidney Dis 2000; et al . of to the patency of vascular access in hemodialysis patients. J Am Nephrol Ravani P, et al . and referral arteriovenous fistula a study. J Am Nephrol et al . Hemodialysis Am J Kidney Dis et al . Vascular access for the on morbidity and J Nephrol et al . Vascular access survival hemodialysis patients in the Am J Kidney Dis J. of vascular access and survival hemodialysis the for in for J Am Nephrol 2005; 16: of vascular access and mortality in hemodialysis patients. Kidney Int 2001; fistula use and disease in long-term elderly hemodialysis of Renal and J Nephrol 16: et al . The of arteriovenous access for hemodialysis to Am J Kidney Dis 2002; 40: of of the arteriovenous fistula on in renal patients. Nephrol Dial Transplant 2001; 16: et al . The of vein as for secondary haemodialysis access J F, et al . and assessment of vascular used as for hemodialysis access. J et al . evaluation of a vascular access graft as with the vascular access graft in hemodialysis J 2001; A and for hemodialysis access. J A of for hemodialysis the J Am Early with for haemodialysis access of a study. J A on for hemodialysis. J for dialysis access. of graft 6 and et al . in prosthetic arteriovenous fistulas for hemodialysis is associated with high and not with in J Am Nephrol Prosthetic arteriovenous fistulas and venous of a high on the of P, A et al . Hemodialysis vascular access to clinical Renal 2002; in vascular J 2000; in arteriovenous fistulas and peripheral it with et al . of a venous at the venous of for hemodialysis vascular access. J 2000; et al . of to prosthetic access for of a clinical J J, et al . The of a venous vein on the primary patency of arteriovenous in patients hemodialysis. J 2000; of venous in prosthetic arteriovenous fistulas for hemodialysis. 2002; 20: et al . evaluation of a graft for hemodialysis vascular access. 2002; in of for hemodialysis access. J Am Nephrol J, in graft of a study. Kidney Int of in arteriovenous fistulas for haemodialysis. J Nephrol of in surgery in Study Group. J Nephrol et al . is for the of graft failure in patients on a J Am Nephrol 2002; P, of the of in arteriovenous fistulas for hemodialysis. et al . Study Group on Hemodialysis of to hemodialysis access graft J Am Nephrol treatment to patency of arteriovenous fistulae and of T, M, in hemodialysis et al . as treatment in dialysis J 2000; in arteriovenous for haemodialysis not of et al . to in prosthetic arteriovenous of a P, et al . for hemodialysis vascular access or 2005; D, T, vein to artery arteriovenous a J, vein for arteriovenous hemodialysis improved patient selection and reduce J 2005; DB, et al . and of hemodialysis access J 2002; J, Allon of arteriovenous in the and upper in hemodialysis patients. J Am Nephrol et al . Prosthetic arteriovenous with J Guideline and should be in vein preservation and of the vascular access. Every patient with chronic kidney disease should have a plan for the vascular access and access sites (Evidence level IV). Guideline in vascular access or veins in renal patients should be and be in a for access (Evidence level IV). Guideline An autogenous fistula should be cannulated when adequate maturation (Evidence level III). Guideline The should be used for of (Evidence level III). A substantial part of the pre-dialysis care is the preservation of veins in the use of the veins of the of the for and [1]. of the vascular autogenous AVF, the correct a on maturation and fistula a in the care for vascular they the patient dialysis, and of the vascular access The vascular access should be before by and patients and to haemodialysis. This includes vascular access and have and for and vascular access for central venous catheters and examination of the vascular access to should be The nephrologist to adequate and in the of care for the vascular access. this care is by the nephrologist should be in the and of in vascular access have for vascular and in the and for in and and should be in the the and the European Vascular or should in the care for vascular access. access and the of specific have the is for the of to graft and the of In autogenous with a vein for the is The of access the For weeks at of of European and of For months after in of of European and of of a fistula may be associated with AVF after weeks should be the maturation period should be ideally fistula and by ultrasonography can the of fistulas on and are 2002; M, et al . to patient vascular and education in hemodialysis. Am J Kidney Dis J. The of in of vascular access J M, T, education of on vascular access for haemodialysis. J 2002; Vascular access and and for Renal et al . of and vascular access failure in of at dialysis in the Nephrol Dial Transplant Ravani P, et al . and referral arteriovenous a study. J Am Nephrol Ravani P, Malberti F, time at Nephrol Dial Transplant 2005; 20: C, F, of of arteriovenous time is also Nephrol Dial Transplant 2005; 20: Guideline to any autogenous arteriovenous fistulae and should be by examination (Evidence level IV). Guideline of access should be performed at a by access (Evidence level II). is to the vascular access to any in autogenous fistulae and may or the and the as it may a and a of the vein after of the the is of the of a in autogenous is indicated a is and a can be in the of a Clinical evaluation for the of prosthetic may be of their to [1]. is in case of of the clinical examination should be by objective There are a of and imaging such as access ultrasonography and with their and The of these is the early of fistula or graft at a by interventional Guideline and can for dialysis venous and arterial can be used to access dialysis on this of and is as the are by and that these have a poor with access the of prosthetic graft and their high use such as and venous venous in to arterial as by et al . that of venous access or the of with can reduce rate in et al . in a that all of should be in of access to access have In graft and There is for any of these In access is of may in access An access in a of per or in fistulae is for For upper fistulas these are for and for fistulae are recommended. and with or surgical reduce the rate of events in as as in patient and of should be as part of dialysis care of to vascular access for research. P, et al . Physical examination for of hemodialysis access J based on hemodialysis access J not with access Kidney Int Schwab M, of hemodialysis fistula Early of venous Kidney Int The dialysis graft and vascular access policy to 2002; 20: P, Vascular access access morbidity and Kidney Int 2001; J et al . venous access or the Kidney Int 2001; J, et al . of vascular access a study. Kidney Int et al . as a of early of native arteriovenous fistulas in hemodialysis patients. Am J Nephrol 2001; et al . A on of on functioning arteriovenous fistulae J Am Nephrol M, D, C, for in native arteriovenous J Am Nephrol 2001; Vascular access is and Guideline a significant is by examination and/or imaging should be performed as as (Evidence level III). Guideline should be performed or delay and imaging should be performed before the (Evidence level II). Guideline the arterial and venous vessels need to be should be performed (Evidence level III). Clinical examination should the key for the of in autogenous arteriovenous fistulae and [1]. However, the on clinical examination is or imaging examination be performed before on and In of treatment of and be surgical is after should also be when for treatment should be surgical or interventional is to allow haemodialysis the vascular access the need for central venous of the is part of any is ultrasonography can be performed to and to the of to the ultrasonography in the of or vascular is adequate for arteries and central veins and can be in is not a at the arteriovenous in are to surgical by examination is in and to in fistulae in should be of the of renal was as the imaging modality of access should be at and to all significant for should be is with or surgical is not However, is performed and after or and after surgical in to the treatment and as as and/or or central venous of renal function, may be et al . of renal in their patient that is and to the for can also be used to plan and may be with a of renal may be by of a the access the arterial also the and arteries can be to be and imaging modality in fistulae with and with non-invasive evaluation of the arterial and venous in examination is performed as it should be with the a of veins with with In all and in a of and a of for the arterial and venous et al . a and and of in the of of and central venous is of the venous to the is of the central veins is and to may to all vessels However, it is and not in is not at the time imaging may be for a of access J, in hemodialysis fistulae and a 2002; in the assessment of arteriovenous fistulas created for hemodialysis with