A wrist radio cephalic AVF, although technically challenging, represents minor surgical trauma with little patient immediate morbidity. This contrasts with upper arm basilic vein transposition (BVT) procedures representing major surgery, especially in the elderly and co-morbid patients.
Despite the “right access for the right patient at the right time” is required, published data suggest that AVFs have better long-term primary patency rate, decreased mortality and require fewer interventions and is associated with the lower morbidity i.e., thrombosis and infections, rate of interventions, and mortality when compared to grafts and Central Vein Catheters (CVC). These differences are mainly explained by the fact that patients having AVFs are about 10 years younger at the time of access placement and with less morbidity compared to those needing a graft or restricted to CVC.
A strict comparison study between various forms of dialysis modes and access types have not been performed and would be unethical as each patient must be treated on an individual basis and specific needs at the time. Hence, many patients need several different dialysis access types during their lifetime (including a renal transplant). Obviously access modalities must not be seen as competitive but rather complementary reflecting individual needs over a lifetime.
Maturation time for an AVF is usually several months compared to grafts and peritoneal dialysis catheters that can be used immediately or within 2-3 weeks.
Many factors influence the dialysis access outcome including referral patterns, especially delayed surgical referral, differences in surgeon proficiency, insurance coverage, gender and ethnic differences. There is a greater risk of failure in women and African Americans. The cost of implantation and maintenance of AVFs are less than with grafts. This is thought to be a major deterrent for using grafts in emerging economies.
Dialysis access steal syndrome (DASS) is more likely with distal brachial artery based AVFs than in those receiving prosthetic grafts or those with radial artery based AVFs or axillary artery inflow site.
Recent endovascular innovations have developed two minimally invasive techniques to create AVF fistula using one or two catheter techniques respectively. Preliminary reports claim 100% technical success and a maturation rate in the 80-90 range. This evolving technology has the potential to revolutionize hemodialysis access but has experienced issues related to acceptance and the high number of maturation procedures and difficulty with cannulation. Its role and place in dialysis access will continue to develop over the next few years with second generation devices under development.
The percutaneous techniques for AVF creation have also been developed for PD catheter insertion representing recent innovations in dialysis access that offer benefits over open surgery. More real-world data is needed to determine long term clinical outcomes and cost-effectiveness. Advantages include widening indications to the very sick patients, as local anesthesia is used, under ultrasound and fluoroscopic guidance. Despite the move away from operating rooms, pAVF procedures require expensive devices, elaborate imaging facility and often added procedures for maturation, making cost-effectiveness an issue. New devices are being developed that may need stricter criteria. Skills training and team collaborations are key factors for MIDA success. The percutaneous PD catheter placement technique is like the endovascular a fact that may be decreasing the HD and PD separation between specialties.
The use of plastic needles used in some regions as in Japan does not adhere to the “rule of 6s” (TABLE 2). It shortens maturation time likely prolongs access survival and uses smaller veins for cannulation such as in antecubital fossa. Application in western societies is mainly prohibited by financial forces controlling dialysis policies
