Maintenance of Hemodialysis Vascular Access and Prevention of Access Dysfunction: A Review.

Background: Current Renal Association guidelines recommend the creation of an arteriovenous fistula as the first choice for hemodialysis access, with artificial grafts kept in reserve. However, maintaining working access comes with significant difficulties, as well as an estimated annual cost to the National Health Service of greater than £84 million. Multiple methods of improving the successful creation of hemodialysis access, improving access maintenance and preventing access dysfunction therefore exist. The aim was to review these methods, including surgical, radiological, and pharmacological techniques.

Methods: The literature was reviewed up to March 2016 for reports of surgical, radiological, and pharmacology approaches to improve maturation, maintain function, and prevent dysfunction of arteriovenous fistulas and artificial access grafts.

Results: Access function has been related to fistula and graft configuration and anastomotic technique. Novel surgical approaches include the use of early-cannulation grafts and biological grafts. Preoperative radiological vessel mapping and access surveillance have both been studied, and once stenosis or thrombosis has occurred, endovascular management techniques for thrombolysis and thrombectomy, along with angioplasty and stenting, are common. Pharmacological trials include the use of antiplatelets, ACE inhibitors, statins, along with perivascular therapies, and other more novel drug targets.

Conclusions: The evidence for the strategies that can be used to maintain access function is highly variable, with many small, observational, and retrospective studies. In the future, the more widespread use of early cannulation grafts, hybrid surgical and endovascular procedures, and the further pursuit of both biological grafts and biological perivascular therapies may yield improvements in vascular access function.