With the increasing incidence of end-stage renal disease, surgeons are tasked with providing vascular access for hemodialysis. The creation of a permanent vascular access for repetitive hemodialysis remains a challenging problem for the vascular surgeon. This is underscored by the fact that the leading cause of hospitalization in the end-stage renal disease population remains “access” related problems.

In patients with progressive renal disease, preservation of access vessels should be stressed. The cephalic, basilic, and antecubital veins of the arm should be protected from intravenous cannulation as much as possible since thrombosis or sclerosis prevents their use for access placement. Likewise, central venous cannulation should be avoided, if possible, and duration of cannulation, if needed, should be minimized to avoid problems with central venous stenosis or occlusions.

Principles to be followed include utilization of arm vessels rather than leg vessels, and, when possible, the nondominant arm should be used. Generally, the access site should be placed in the forearm first so that more proximal sites will be available for subsequent use.

Arteriosclerotic arteries should be avoided, and a long segment of patent vein is required to accommodate multiple cannulations. These “accesses” will be cannulated with two large needles three times a week for the remainder of the patientís life with dialysis taking three to four hours. The chosen site should allow easily cannulation and be positioned so that patient comfort is possible during hemodialysis.

Autogenous access has significantly better long-term performance and should be the first consideration in most patients. These arteriovenous fistulas (accesses) are constructed by anastomosing the patient’s veins to arteries thus resulting in arterialization of a venous segment to provide high enough flow rates for dialysis and likewise to provide enough dilatation of the venous segments for ease of cannulation with the large bore needles required for hemodialysis. When autogenous access is not possible, then a similar connection between the arterial and venous system is accomplished utilizing prosthetic graft material.

The optimal access for long-term hemodialysis remains a radial artery/cephalic vein arteriovenous fistula. Unfortunately, advanced arteriosclerosis of the radial artery and/or lack of a patent forearm cephalic vein precludes this in many instances. Other autogenous options for native fistula creation include transposition of the basilic vein in the forearm and/or transposition of the basilic vein in the upper arm, or construction of a brachiocephalic fistula in the upper arm. Should autogenous access not be possible due to inadequacy of these superficial venous structures, then arteriovenous fistula placement is created with a prosthetic graft material, usually PTFE. These grafts may be configured in a number of different methods to allow ease of cannulation.

In summary, the primary goal with end-stage renal disease should be placement of an autogenous arteriovenous fistula. These native fistulas have a longer useful life without interventions and are associated with less morbidity and cost of maintenance. When placement of a native arteriovenous fistula is not possible, prosthetic options as discussed above then need to be considered.