Global hemodialysis vascular access care: Three decades of evolution.

The development of vascular access for hemodialysis has come a long way since 1943 when the first hemodialysis treatment was performed in humans by connecting an artery and vein using an external glass canula. Since then, vascular access care has evolved robustly through contributions from numerous countries and professional nephrology societies, worldwide. To understand the global distribution and contribution of different specialties to medical literature on dialysis vascular access care, we performed a literature search from 1991 to 2021 and identified 2768 articles from 74 countries. The majority of publications originated from the United States (41.5%), followed by China (5.1%) and the United Kingdom (4.6%). Our search results comprise of observational studies (43%), case reports/series (27%), review articles (16.5%) and clinical trials (12%). A large proportion of articles were published in Nephrology journals (49%), followed by General Medicine (14%), Surgery (10%), Vascular Medicine (8%), and Interventional Radiology journals (4%). With the introduction of interventional nephrology, nephrologists will be able to assume the majority of the responsibility for dialysis vascular access care and above all maintain a close interdisciplinary collaboration with other specialties to provide optimum patient care. In this review article, we discuss the history, evolving knowledge, challenges, educational opportunities, and future directions of dialysis vascular access care, worldwide.

Tunneled femoral dialysis catheter: Practical pointers.

One of the most challenging aspects of providing end-stage kidney disease care is to achieve adequate long-term access to the bloodstream to support hemodialysis (HD) therapy. Although upper extremity arteriovenous fistula remains the vascular access of choice for patients on HD, complications such as central venous stenosis, access thrombosis, or exhaustion of suitable access sites in the upper extremity, ultimately result in pursuing vascular access creation in the lower extremity. The current review focuses on the indications, contraindications, and clinically relevant practical procedural tips to successfully place a tunneled femoral dialysis catheter. The review highlights some of the prevailing misconceptions regarding femoral catheter placement practices.

Central Venous Catheters for Hemodialysis-the Myth and the Evidence.

Hemodialysis-central venous catheter (HD-CVC) insertion is a most often performed procedure, with approximately 80% of patients with end-stage kidney disease in the United States initiating kidney replacement therapy through a HD-CVC. Certain adverse events arising from HD-CVC placement, including catheter-related bloodstream infections (CR-BSIs), thrombosis, and central vein stenosis, can complicate the clinical course of patients and lead to considerable financial impact on the health care system. Medical professionals with different training backgrounds are responsible for performing this procedure, and therefore, comprehensive operator guidelines are crucial to improve the success rate of HD-CVC insertion and prevent complications. In this review article, we not only discuss the basic principles behind the use of HD-CVCs but also address frequently asked questions and myths regarding catheter asepsis, length selection, tip positioning, and flow rate assessment.

New Devices and Technologies for Hemodialysis Vascular Access: A Review.

In the United States, hemodialysis remains the most common treatment modality for kidney failure, chosen by almost 90% of incident patients. A functioning vascular access is key to providing adequate hemodialysis therapy. Recently, major innovations in devices and technology for hemodialysis vascular access care have rapidly changed the landscape. Novel endovascular devices for creation of arteriovenous fistulas may offer a solution to the barriers encountered in initiating maintenance hemodialysis with a permanent vascular access rather than a central venous catheter (CVC). Furthermore, in the prevalent hemodialysis population, the minimally invasive endovascular arteriovenous fistula procedure should help improve long wait times for vascular access creation, which remains a major barrier to reducing CVC dependence. Bioengineered grafts are being developed and may offer another option to polytetrafluoroethylene grafts. Early studies with these biocompatible grafts are promising, as additional studies continue to evaluate their clinical outcomes in comparison to cryopreserved or synthetic options. Prolonging the vascular access patency with appropriate use of devices such as drug-coated balloons and stent grafts may complement the novel techniques of creating arteriovenous access. Finally, innovative solutions to treat stenosed and occluded thoracic central veins can provide an approach to creating a vascular access and allow patients with exhausted vasculature to remain on hemodialysis. The robust developments in hemodialysis vascular access are likely to change practice patterns in the near future.

Monitoring and Surveillance of Hemodialysis Access.

Access surveillance using invasive or noninvasive methods with an objective to improve access patency and decrease hospital admissions for access dysfunction in dialysis population has been promoted, but its success to predict incipient thrombosis and subsequent access failure is a controversial topic. Some studies have shown improvement in access outcomes, while others have failed to demonstrate an ideal method to diagnose access problems. Furthermore, the use of endovascular interventions such as percutaneous transluminal angioplasty to timely correct access problem might itself be a promoter of neointimal hyperplasia and restenosis during balloon angioplasty. There are significant costs and efforts associated with routine dialysis surveillance; therefore, it is necessary to understand whether such programs will help improve access-related problems and guarantee adequate dialysis care. It is generally agreed upon that despite the lack of guaranteed success of surveillance, such strategies have helped improve dialysis management, resulted in decreased costs and hospitalizations, and represented clinically relevant indications of failure prior to planning any radiological or surgical intervention. In this study, the authors review monitoring and surveillance measures in place, and their associated merits and limitations to detect stenosis and prevent incidences of vascular access thrombosis.