Advances in Vascular Access

Vascular access is the lifeline of the hemodialysis patient. However, many patients lack early nephrology care that results in late referral for vascular access placement and dialysis initiation with a central venous catheter in 80% of the United States incident dialysis population. Despite these hurdles, arteriovenous fistulae (AVF) have doubled, to 65%, in the United States prevalent hemodialysis population over the last decade. The endovascular revolution has resulted in better rescue and maintenance of established AVF and arteriovenous grafts (AVG). Newer conduits are available for those needing an AVG, and a number of devices have been approved or are in trials to address specific issues, such as high-grade central stenosis, deep AVF, slow maturation, need for immediate cannulation, and persistent backwall injury. Finally, new techniques to deal with distal hypoperfusion ischemic syndrome, or “steal syndrome,” have been developed.