Physicians involved in managing the ever-growing population of patients with end stage kidney disease (ESKD) continue to debate what is the “best” vascular access for hemodialysis (HD). With the initiation of the “Fistula First Breakthrough Initiative” in 2003, there was a strong directive to increase the rates of arteriovenous fistula (AVF) use and decrease the rate of catheter use. As advocated by national guidelines, physicians believed that an AVF was the preferred access choice for most patients. This initiative was somewhat successful, and the rates of AVF use in the United States increased from 35% in 2003 to 63% in 2017 but still fell short of the original goal set out by the Centers for Medicare & Medicaid Services of 66% (1). The data to support the advantages of AVF have always been clear: fewer infectious and thrombotic complications, better patency, and lower rates of reinterventions. However, as we created more AVFs in the past two decades, the drawback has become apparent. The maturation process could be as long as 4 months, requiring multiple interventions and a primary failure rate between 30% and 50% (2).
It became clear that AVF is not the “gold standard” for HD access. A “one size fits all” strategy is not ideal in this complex patient population, and a more patient-centered approach to the creation of vascular access is needed. In 2019, the Kidney Disease Outcomes Quality Initiative (KDOQI) ESKD Life-Plan was developed, which advocates for “right access in the right patient at the right time for the right reasons” (3). The Life-Plan encourages physicians (nephrologists, vascular surgeons, interventional radiologists, etc.) to not only consider arterial and venous anatomy when planning HD access but also to take into consideration other factors including comorbidities, life expectancy, and patient preference. There is a significant shift from previous recommendations, as Life-Plan does not emphasize a strong preference for AVF utilization. Although this individualized approach provides an opportunity for more patient-centered care, it makes the decision-making process more challenging.
My Vascular Access (a website and application) was developed by Kidney CARE Network International to aid physicians and patients in developing the most appropriate individualized vascular access life plan. My Vascular Access uses two algorithms and integrates the recommendations from KDOQI guidelines, along with patient-specific information, such as age, functional status, and vascular anatomy. The first algorithm approaches the problem based on the clinical situation. After choosing from a set of pre-selected clinical situations and answering questions related to the patient-specific data, the algorithm then provides feedback regarding which access type to consider. The second algorithm on the app allows providers to input data, such as age, need for dialysis, functional status, body mass index, and size of veins and arteries, and gives a list of possible access types, ranked by appropriateness.
The app is based on the latest available clinical data and expert opinion from vascular access experts composed of surgeons, nephrologist, and interventionalists. The recommendations were generated by the algorithms based on a consensus process of a large data set that was validated by access experts and published in the Journal of Vascular Surgery in a 2017 article, titled “Establishing patient-specific criteria for selecting the optimal upper extremity vascular access procedure” (4). The study used the RAND/University of California Los Angeles Appropriateness Method (RAM) to assess 3816 clinical scenarios for the suitability of AVF vs. AV graft (AVG). Eleven vascular access experts rated the appropriateness of each scenario, and 864 clinical scenarios were then created in which the experts were given the option to choose between AVF or AVG as the first access operation. Interestingly, in 25% of those scenarios, AVG was rated more appropriate than AVF. There are, of course, limitations to this study. Only upper-extremity AV access was taken into account, and the option of Hemodialysis Reliable Outflow (HeRO) catheters or leg grafts was not included. Furthermore, all possible combinations of clinical scenarios could not be included for the feasibility study.
The first human HD was performed approximately 100 years ago, and the first AVF was created nearly 60 years ago (5). Despite tremendous advances in medical care since then, creating and maintaining well-functioning HD access continue to be challenges. A clear answer of AVF vs. AVG in terms of survival, morbidity, and cost benefit would require a large, multicenter randomized trial. Until this trial is available, the decision is based on the clinical judgment of the providers caring for the patient. The My Vascular Access app aids in this decision-making and allows providers to easily identify patients who may fall into the gray zone of whether or not they will benefit from an AVF. It uses a data-centered approach to take the guesswork out of optimizing vascular access in our most challenging patients. Appropriate patient selection can avoid unnecessary interventions and surgical procedures, which have been increasing in frequency (6). My Vascular Access can be a useful tool for every provider who takes care of patients on HD. As we continue our journey to develop the optimal strategy for HD access planning, we need to integrate the best available evidence and tools as well as individual patients’ circumstances and preferences.
- 1. ↑
Allon M, Robbin ML. Increasing arteriovenous fistulas in hemodialysis patients: Problems and solutions. Kidney Int 2002; 62:1109–1124. doi: 10.1111/j.1523-1755.2002.kid551.x
- 2. ↑
Li H, et al. Unanticipated late maturation of an arteriovenous fistula after creation of separate graft access. Quant Imaging Med Surg 2018; 8:444–446. doi: 10.21037/qims.2018.01.03
- 3. ↑
Lok CE, et al. KDOQI clinical practice guideline for vascular access: 2019 Update. Am J Kidney Dis 2020; 75 (4 Suppl 2):S1–S164. doi: 10.1053/j.ajkd.2019.12.001
- 4. ↑
Woo K, et al. Establishing patient-specific criteria for selecting the optimal upper extremity vascular access procedure. J Vasc Surg 2017; 65:1089–1103.e1. doi: 10.1016/j.jvs.2016.10.099
- 5. ↑
Brescia MJ, et al. Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N Engl J Med 1966; 275:1089–1092. doi: 10.1056/NEJM196611172752002
- 6. ↑
Harms JC, et al. Outcomes of arteriovenous fistulas and grafts with or without intervention before successful use. J Vasc Surg 2016; 64:155–162. doi: 10.1016/j.jvs.2016.02.033