Advertisement

Editor's Choice – Vascular Access: 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS)

  • Author Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Jürg Schmidli
    Correspondence
    Corresponding author. Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland. Tel: +41 31 632 2602; Fax: +41 31 632 2919.
    Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Search for articles by this author
  • Author Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Matthias K. Widmer
    Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Search for articles by this author
  • Author Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Carlo Basile
    Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Search for articles by this author
  • Author Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Gianmarco de Donato
    Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Search for articles by this author
  • Author Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Maurizio Gallieni
    Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Search for articles by this author
  • Author Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Christopher P. Gibbons
    Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Search for articles by this author
  • Author Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Patrick Haage
    Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Search for articles by this author
  • Author Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    George Hamilton
    Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Search for articles by this author
  • Author Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Ulf Hedin
    Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Search for articles by this author
  • Author Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Lars Kamper
    Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Search for articles by this author
  • Author Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Miltos K. Lazarides
    Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Search for articles by this author
  • Author Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Ben Lindsey
    Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Search for articles by this author
  • Author Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Gaspar Mestres
    Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Search for articles by this author
  • Author Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Marisa Pegoraro
    Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Search for articles by this author
  • Author Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Joy Roy
    Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Search for articles by this author
  • Author Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Carlo Setacci
    Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Search for articles by this author
  • Author Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    David Shemesh
    Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Search for articles by this author
  • Author Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Jan H.M. Tordoir
    Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Search for articles by this author
  • Author Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Magda van Loon
    Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    Search for articles by this author
  • Author Footnotes
    b ESVS Guidelines Committee: Philippe Kolh (Liege, Belgium), chair), Gert J. de Borst (Utrecht, Netherlands, co-chair and guideline coordinator), Nabil Chakfe (Strasbourg, France), Sebastian Debus (Hamburg, Germany), Rob Hinchliffe (Bristol, UK), Stavros Kakkos (Patras, Greece), Igor Koncar (Belgrade, Serbia), Jes Lindholt (Odense, Denmark), Ross Naylor (Leicester, UK), Melina Vega de Ceniga (Galdakao, Spain), Frank Vermassen (Ghent, Belgium), Fabio Verzini (Perugia, Italy).
    ESVS Guidelines Committee
    Footnotes
    b ESVS Guidelines Committee: Philippe Kolh (Liege, Belgium), chair), Gert J. de Borst (Utrecht, Netherlands, co-chair and guideline coordinator), Nabil Chakfe (Strasbourg, France), Sebastian Debus (Hamburg, Germany), Rob Hinchliffe (Bristol, UK), Stavros Kakkos (Patras, Greece), Igor Koncar (Belgrade, Serbia), Jes Lindholt (Odense, Denmark), Ross Naylor (Leicester, UK), Melina Vega de Ceniga (Galdakao, Spain), Frank Vermassen (Ghent, Belgium), Fabio Verzini (Perugia, Italy).
    Search for articles by this author
  • Philippe Kolh
    Search for articles by this author
  • Gert J. de Borst
    Search for articles by this author
  • Nabil Chakfe
    Search for articles by this author
  • Sebastian Debus
    Search for articles by this author
  • Rob Hinchliffe
    Search for articles by this author
  • Stavros Kakkos
    Search for articles by this author
  • Igor Koncar
    Search for articles by this author
  • Jes Lindholt
    Search for articles by this author
  • Ross Naylor
    Search for articles by this author
  • Melina Vega de Ceniga
    Search for articles by this author
  • Frank Vermassen
    Search for articles by this author
  • Fabio Verzini
    Search for articles by this author
  • Author Footnotes
    c ESVS Guidelines Reviewers: Markus Mohaupt (Bern, Switzerland), Jean-Baptiste Ricco (Strasbourg, France), Ramon Roca-Tey (Barcelona, Spain).
    ESVS Guidelines Reviewers
    Footnotes
    c ESVS Guidelines Reviewers: Markus Mohaupt (Bern, Switzerland), Jean-Baptiste Ricco (Strasbourg, France), Ramon Roca-Tey (Barcelona, Spain).
    Search for articles by this author
  • Markus Mohaupt
    Search for articles by this author
  • Jean-Baptiste Ricco
    Search for articles by this author
  • Ramon Roca-Tey
    Search for articles by this author
  • Author Footnotes
    a Writing Group: Jürg Schmidli∗ (Bern, Switzerland), Matthias K. Widmer (Bern, Switzerland), Carlo Basile (Bari, Italy), Gianmarco de Donato (Siena, Italy), Maurizio Gallieni (Milan, Italy), Christopher P. Gibbons (Banbury, UK), Patrick Haage (Witten, Germany), George Hamilton (London, UK), Ulf Hedin (Stockholm, Sweden), Lars Kamper (Witten, Germany), Miltos K. Lazarides (Alexandroupoli, Greece), Ben Lindsey (London, UK), Gaspar Mestres (Barcelona, Spain), Marisa Pegoraro (Milan, Italy), Joy Roy (Stockholm, Sweden), Carlo Setacci (Siena, Italy), David Shemesh (Jerusalem, Israel), Jan H.M. Tordoir (Maastricht, The Netherlands), Magda van Loon (Maastricht, The Netherlands).
    b ESVS Guidelines Committee: Philippe Kolh (Liege, Belgium), chair), Gert J. de Borst (Utrecht, Netherlands, co-chair and guideline coordinator), Nabil Chakfe (Strasbourg, France), Sebastian Debus (Hamburg, Germany), Rob Hinchliffe (Bristol, UK), Stavros Kakkos (Patras, Greece), Igor Koncar (Belgrade, Serbia), Jes Lindholt (Odense, Denmark), Ross Naylor (Leicester, UK), Melina Vega de Ceniga (Galdakao, Spain), Frank Vermassen (Ghent, Belgium), Fabio Verzini (Perugia, Italy).
    c ESVS Guidelines Reviewers: Markus Mohaupt (Bern, Switzerland), Jean-Baptiste Ricco (Strasbourg, France), Ramon Roca-Tey (Barcelona, Spain).
Open ArchivePublished:May 02, 2018DOI:https://doi.org/10.1016/j.ejvs.2018.02.001

      Keywords

      Abbreviations

      Abbreviation and Term (Synonym)

      ABI
      Ankle brachial index
      ACE
      Angiotensin converting enzyme
      AVF
      Arteriovenous fistula (Synonym: Autogenous or native fistula)
      AVG
      Arteriovenous graft (Synonym: Prosthetic graft)
      BBAVF
      Brachiobasilic AVF
      BCAVF
      Brachiocephalic AVF
      BVT
      Basilic vein transposition
      CE-MRA
      Contrast enhanced magnetic resonance angiography
      CHF
      Congestive heart failure
      CKD
      Chronic kidney disease
      CO
      Cardiac output
      CO2
      Carbon dioxide
      CPR
      Cardiopulmonary recirculation
      CTA
      Computed tomography angiography
      CVD
      Cardiovascular disease
      CVC
      Central venous catheter
      CVOD
      Central venous occlusive disease
      DBI
      Digital brachial index
      DOPPS
      Dialysis outcomes and practice patterns study
      DEB
      Drug eluting balloon
      DRIL
      Distal revascularisation and interval ligation
      DSA
      Digital subtraction angiography
      DUS
      Duplex ultrasonography
      ePTFE
      expanded polytetrafluoroethylene
      EJVES
      European Journal of Vascular and Endovascular Surgery
      ESC
      European Society of Cardiology
      ESRD
      End stage renal disease
      ESVS
      European Society for Vascular Surgery
      GFR
      Glomerular filtration rate
      GSV
      Great saphenous vein
      HD
      Haemodialysis
      HD catheter
      Catheter of any kind used for haemodialysis
      HeRO®
      Haemodialysis Reliable Outflow device
      HIV
      Human immunodeficiency virus
      IMN
      Ischaemic monomelic neuropathy
      IVC
      Inferior vena cava
      KDOQI
      Kidney diseases outcome quality initiative
      Kt/V
      Dialysis rate
      LEAVG
      Lower extremity AVG
      LEAD
      Lower extremity atherosclerotic disease
      LMWH
      Low molecular weight heparin
      MAP
      Mean arterial pressure
      MRA
      Magnetic resonance angiography
      MRI
      Magnetic resonance imaging
      MRSA
      Methicillin resistant Staphylococcus aureus
      NCE-MRA
      Non-contrast enhanced magnetic resonance angiography
      NIH
      Neointimal hyperplasia (Synonym: Myointimal hyperplasia)
      NKF-KDOQI
      National Kidney Foundation for Kidney disease outcome quality initiative
      NPWT
      Negative pressure wound therapy
      NSF
      Nephrogenic systemic fibrosis
      ntCVC
      Non tunnelled central venous catheter (Synonym: indwelling catheter without cuff)
      PAVA
      Proximalisation of the arteriovenous anastomosis
      PD
      Peritoneal dialysis
      PICC
      Peripherally inserted central venous catheter
      PNV
      Pre-nephrology visit
      PTA
      Percutaneous transluminal angioplasty (Synonym: balloon angioplasty)
      Qa
      Access blood flow
      Qb
      Blood pump flow delivered to the dialyser
      RCAVF
      Radiocephalic AVF (Synonoym: Brescia-Cimino fistula)
      RCT
      Randomised controlled trial
      RRT
      Renal replacement therapy
      RUDI
      Revision using distal inflow
      SFA
      Superficial femoral artery
      FV
      Femoral vein (formerly superficial femoral vein)
      FVT
      Femoral vein transposition
      Stent graft
      Former covered stent
      tcCVC
      Tunnelled cuffed central venous catheter (Synonym: indwelling catheter with cuff)
      UDT
      Ultrasound dilution technique
      URR
      Urea reduction ratio
      VA
      Vascular access
      VAILI
      Vascular access induced limb ischaemia
      VAS
      Vascular Access Society
      VP
      Venous pressure
      VP/MAP
      Venous pressure adjusted for the mean arterial pressure
      WC
      Writing Committee

      1. Methodology and grading of recommendations

      1.1 Purpose

      The European Society for Vascular Surgery (ESVS), in line with its mission, appointed the Vascular Access (VA) Writing Committee (WC) to write the current clinical practice guidelines document for surgeons and physicians who are involved in the care of patients with haemodialysis (HD) and VA. The goal of these Guidelines is to summarise and evaluate all the currently available evidence to assist physicians in selecting the best management strategies for all patients needing VA or for pathologies derived from a VA. However, each physician must make the ultimate decision regarding the particular care of an individual patient.
      • Field M.J.
      • Lohr K.N.
      Clinical practice guidelines: directions for a new program. Committee to advise the Public-Health Service on clinical practice guidelines.
      • Field M.J.
      • Lohr K.N.
      Guidelines for clinical practice: from development to use.
      Patients with VA for HD are complex and also subject to significant clinical practice variability, although a valid evidence base is available to guide recommendations. The significant technical and medical advances in VA have enabled guidelines to be proposed with greater supporting evidence than before. Potential increases in healthcare costs and risks due to industry and public driven use of novel treatment options make the current guidelines increasingly important.
      • Dubois R.W.
      • Dean B.B.
      Evolution of clinical practice guidelines: evidence supporting expanded use of medicines.
      • Sood R.
      • Sood A.
      • Ghosh A.K.
      Non-evidence-based variables affecting physicians' test-ordering tendencies: a systematic review.
      • Manchanda P.
      • Honka E.
      The effects and role of direct-to-physician marketing in the pharmaceutical industry: an integrative review.
      • Win H.K.
      • Caldera A.E.
      • Maresh K.
      • Lopez J.
      • Rihal C.S.
      • Parikh M.A.
      • et al.
      Clinical outcomes and stent thrombosis following off-label use of drug-eluting stents.
      Many clinical situations involving patients with HD and VA have not been studied by randomised clinical trials. Nevertheless, patient care must be delivered and clinical decisions made in these situations. Therefore, this document should also provide guidance when extensive level A evidence is unavailable and in these situations recommendations are determined on the basis of the best currently available evidence.
      By providing information on the relevance and validity of the quality of evidence, the reader will be able to gather the most important and evidence based information relevant to the individual patient.
      This document is intended to be a guide, rather than a set of rules, allowing flexibility for specific patients' circumstances. The current clinical practice guidelines document provides recommendations for the clinical care of patients with HD and VA including pre-operative, peri-operative and post-operative care and long-term maintenance.

      1.2 Methodology

      The VA WC was formed by members of the ESVS and Vascular Access Society (VAS) from different European countries, various academic and private hospitals, and includes vascular surgeons, nephrologists, radiologists and clinical nurses in order to maximise the applicability of the final guideline document. The WC met in September 2012 for the first time to discuss the purpose, contents, methodology and timeline of the following recommendations.
      Table 1Levels of evidence.
      Table thumbnail fx1
      Table 2Grades of strength of recommendations according to the ESC grading system.
      Table thumbnail fx2
      For each recommendation, two members of the WC assessed the strength of a recommendation and the quality of supporting evidence independently. A full master copy of the manuscript with all recommendations was electronically circulated and approved by all WC members. Recommendations that required consensus were discussed and voted upon at meetings and by email among all members of the WC. This system permitted strong recommendations supported by low or very low quality evidence from downgraded RCTs or observational studies only when a general consensus among the WC members and reviewers was achieved. Meta-analyses are quoted in the recommendations according to the following rule: if the recommendation was either of high or low quality the meta-analysis was quoted and the individual studies were not explored. If it was a “grey area” and mixed opinions on the included meta-analysis studies were present, the original data were examined to clearly present the “mixed” findings within several studies. Two members of the WC have prepared each part of the guidelines document. An internal review process was performed before the manuscript was sent to the ESVS Guidelines Committee and selected invited independent external reviewers. External reviewers made critical suggestions, comments and corrections on all preliminary versions of these guidelines. In addition, each member participated in the consensus process concerning conflicting recommendations. The final document has been approved by the ESVS Guidelines Committee and submitted to the European Journal of Vascular and Endovascular Surgery (EJVES). Further updated guidelines documents on VA will be provided periodically by the ESVS when new evidence and/or new clinical practice arise in this field, which could occur every three years.
      To optimise the implementation of the current document, the length of the guidelines has been kept as short as possible to facilitate access to guideline information. Conflicts of interest from each WC member were collected prior to the writing process. These conflicts were assessed and accepted by each member of the WC and are reported in this document. In addition, the WC agreed that all intellectual work should be expressed without any interference beyond the honesty and professionalism of all its members during the writing process.

      1.3 Definitions

      1.3.1 Definition of vascular access

      Patients with acute renal failure or end stage renal disease require renal replacement therapy, which includes peritoneal dialysis (PD), haemodialysis (HD) or kidney transplantation (Fig. 1). A VA is essential for patients on HD and can be accomplished with central venous catheters (CVC), but also with arterialisation of a vein or by interposition of a graft between an artery and a vein for the insertion of HD needles. The blood flow available for HD should reach at least 300 ml/min and preferably 500 ml/min depending on the VA modality to allow a sufficient HD.
      Figure thumbnail gr1
      Figure 1Flowchart of renal replacement treatment options.

      1.3.2 Other definitions

      Arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) are established terms to characterise a special kind of VA in patients on HD. An AVF is defined as an autogenous anastomosis between an artery and a vein and an AVG is defined as a VA using a prosthetic graft.
      At the beginning of this millennium interventional radiologists and vascular surgeons attempted to clarify the terminology dealing with HD access.
      • Gray R.J.
      • Sacks D.
      • Martin L.G.
      • Trerotola S.O.
      Reporting standards for percutaneous interventions in dialysis access. Technology Assessment Committee.
      • Sidawy A.N.
      • Gray R.
      • Besarab A.
      • Henry M.
      • Ascher E.
      • Silva Jr., M.
      • et al.
      Recommended standards for reports dealing with arteriovenous hemodialysis accesses.
      Some of these definitions have been revised and
      • Lee T.
      • Mokrzycki M.
      • Moist L.
      • Maya I.
      • Vazquez M.
      • Lok C.E.
      Standardized definitions for hemodialysis vascular access.
      further refinements made; there is still ongoing discussion amongst VA specialists. Nevertheless outlined below are the definitions that are believed to be currently accepted by the majority of clinicians in the field.
      Incidence is the proportion of a given population developing a new condition or experiencing an event within a specified period of time. This could be for example, the number of patients experiencing an event (e.g. patients undergoing VA creation) divided by the number of a given population (e.g. the number of patients undergoing HD). For a disease, incidence can be expressed as the number of patients per million population per year.
      Prevalence is the total number of cases of a disease within a given population; it includes both new and continuing patients with a certain disease and is expressed as number of patients per million population. Prevalence is a function of incidence (new cases) and outcomes (death or cure).
      Point prevalence in %: Number of patients using a specific type of VA at a given point of time multiplied by 100 and divided by the number of patients with a VA at this time.
      Period prevalence in %: The mean number of patients using a specific VA over a given time (one year) multiplied by 100 and divided by all the patients using a VA during the same time period.
      Hospitalisation days/1000 access days: The numerator is the total number of days of hospitalisation for the study population. The denominator is calculated as the number of days from VA creation or the start date of a study period to permanent (unsalvageable) VA failure, the end of study period, death of the patient, transfer from the dialysis unit or a change in renal replacement modality (PD or transplantation). The calculated rate is the total number of hospitalisation days ⁄ total number of VA days multiplied by 1000 to express the number of hospitalisation days per 1000 VA days.
      Access abandonment: The day on which a VA is deemed to be permanently unusable or not suitable for cannulation.
      Primary VA: Creation of a functioning VA for the first time.
      Secondary VA: Ordinary VA creation with AVF or AVG at any location after a failed primary VA (tertiary VA excluded).
      Tertiary VA: VA using great saphenous vein (GSV) or femoral vein (FV) translocated to the arm or leg. Unusual VA procedures such as upper or lower limb arterio-arterial loops are included in this category.
      Transposition: Relocation of an autogenous vein to a new (more superficial) position in the soft tissues of the same anatomical area (e.g. an upper arm AVF with transposition of the basilic vein).
      Translocation: The prepared vein is completely disconnected and inserted in a new anatomical area to create an AVF.
      Superficialisation: The index vein is transposed in the subcutaneous tissue and positioned closer to the skin.
      Kaplan-Meier life table analysis: A statistical method for calculating time dependent clinical outcomes can be documented such as VA patencies, or infection free survival rates.
      Primary patency: The interval between VA creation and the first re-intervention (intervention free VA survival) for VA dysfunction or thrombosis, the time of measurement of patency or the time of its abandonment.
      Assisted primary patency: The interval between VA creation and the first occlusion (thrombosis free VA survival) or measurement of patency including operative/endovascular interventions to maintain the VA.
      Primary functional patency: The interval between the first use (first cannulation) of a newly created VA and the first re-intervention to rescue the VA or to its abandonment.
      Secondary patency: The interval between VA creation and the abandonment of this VA (i.e. thrombosis) after one or more interventions or the time of measurement of patency including achievement of a censored event (death, change of HD modality, loss of follow-up).
      Maturation and functionality of VA: Changes that occur in the VA after its creation (increase in VA flow and AVF diameter, wall structure changes, AVG tissue to graft incorporation) making it suitable over time for cannulation.
      Mature VA: A VA that is expected to be suitable for HD access and considered appropriate for cannulation with two needles and expected to deliver sufficient blood flow throughout the HD. Therefore it is a pre-cannulation definition.
      Functional VA: A VA is functional when it has been cannulated successfully with two needles, over a period of at least 6 HD sessions during a 30 day period, and delivered the prescribed blood flow throughout the HD and achieved adequate HD (usually at least 300 ml/ min). Therefore, it is a post-cannulation definition.
      Monitoring: Examination and evaluation of the VA by means of physical examination to detect physical signs that suggest the presence of VA dysfunction.
      Surveillance: Periodic evaluation of a VA using haemodynamic tests. This may trigger further diagnostic evaluation.
      VA induced (limb) ischaemia: Extremity malperfusion after VA creation. It can be classified in four stages:
      • stage 1: slight coldness, numbness, pale skin, no pain
      • stage 2: loss of sensation, pain during HD or exercise
      • stage 3: rest pain
      • stage 4: tissue loss affecting the distal parts of the limb, usually the digits
      This definition is more appropriate than ‘steal’ which describes the physiological phenomenon of (even retrograde) blood flow recruitment towards the AVF/AVG.
      Recirculation: The return of dialysed blood to the systemic circulation without full equilibration (NKF-DOQI definition).
      Kt/V: A parameter to quantify the adequacy of the HD: K=Dialyser clearance of urea, t=effective time of HD V=volume of urea distribution, approximately equal to the patient's body water (60% of the body mass).
      Early VA failure: A VA that has occluded within 24 hours of creation.
      Early dialysis suitability failure: A VA that cannot be used by the third month following creation despite radiological or surgical intervention.
      Late dialysis suitability failure: A VA that is not usable after more than 6 months despite radiological or surgical intervention.
      Cannulation failure: Failure is defined as the inability to place and secure two dialysis needles.
      Non-tunnelled CVC (ntCVC): An uncuffed catheter providing temporary VA for HD.
      Tunnelled cuffed CVC (tcCVC): A subcutaneously tunnelled dual lumen catheter with a cuff that can be used for VA if HD is expected to last for more than two weeks.
      Catheter related bacteraemia:
      Proven: Bacteraemia with at least one positive percutaneous peripheral vein blood culture and where either the same pathogen was cultured from the catheter tip or a blood culture drawn from a catheter that has a >3 fold greater bacterial colony count than those drawn from a peripheral vein.
      Probable: Bacteraemia with positive blood cultures obtained from a catheter and/or peripheral vein in a patient where there is no clinical evidence of an alternative source of an infection.
      Catheter exit site infection:
      Proven: The presence of a purulent discharge or erythema, induration/and or tenderness at the catheter exit site with a positive bacteriological culture of the serous discharge.
      Probable: The clinical signs of infection with negative cultures from the discharge or blood without signs of irritation from gauze, stitches or the cleansing agent.
      Catheter tunnel infection:
      Proven: The presence of purulent discharge from the tunnel or erythema, induration and/or tenderness over the catheter tunnel with a positive culture.
      Probable: Clinical signs of infection around the catheter site with negative cultures from the discharge or blood.
      Primary catheter site patency: Interval between catheter insertion and the first intervention to restore the catheter's function.
      Secondary catheter site patency: Interval between catheter insertion and exchange or removal of the catheter for any reason.
      Continuous catheter site: The time period from initial catheter insertion to catheter site abandonment for any reason including the time period after continuous catheter exchanges in the same target vessel. The time period and number of exchanges are documented e.g. 12 months [3 catheters].
      Catheter dysfunction: This is the first occurrence of either a peak flow of 200 ml/minute or less for 30 minutes during HD, a mean blood flow of 250 ml/minute or less during two consecutive dialyses or the inability to initiate HD resulting from an inadequate blood flow, despite attempts to restore patency.

      2. Epidemiology of chronic kidney disease (CKD) stage 5

      2.1 Epidemiology of chronic kidney disease

      Chronic kidney disease (CKD) is a worldwide public health problem. CKD is classified into five stages (Table 3), but renal insufficiency is restricted to stages 3–5, with a glomerular filtration rate (GFR) below 60 ml/min per 1.73 m2 for 3 months or more irrespective of the cause.
      K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification.
      Table 3Classification of chronic kidney disease based on glomerular filtration rate (GFR).
      • Gray R.J.
      • Sacks D.
      • Martin L.G.
      • Trerotola S.O.
      Reporting standards for percutaneous interventions in dialysis access. Technology Assessment Committee.
      • Sidawy A.N.
      • Gray R.
      • Besarab A.
      • Henry M.
      • Ascher E.
      • Silva Jr., M.
      • et al.
      Recommended standards for reports dealing with arteriovenous hemodialysis accesses.
      • Lee T.
      • Mokrzycki M.
      • Moist L.
      • Maya I.
      • Vazquez M.
      • Lok C.E.
      Standardized definitions for hemodialysis vascular access.
      StageDescriptionGFR mL/min/1.73 m2
      Stage 1Kidney damage with normal or elevated GFR90+
      Stage 2Kidney damage with mildly decreased GFR60–89
      Stage 3Moderately decreased GFR30–59
      Stage 4Severely decreased GFR15–29
      Stage 5End stage renal disease (ESRD)<15 or on dialysis
      The true incidence and prevalence of CKD within a community are difficult to ascertain as early to moderate CKD is usually asymptomatic. Most studies point to a prevalence of CKD of around 10%, albuminuria of around 7%, and GFR below 60 ml/min per 1.73 m2 of around 3%.
      • Coresh J.
      • Astor B.C.
      • Greene T.
      • Eknoyan G.
      • Levey A.S.
      Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey.
      • Levey A.S.
      • de Jong P.E.
      • Coresh J.
      • El Nahas M.
      • Astor B.C.
      • Matsushita K.
      • et al.
      The definition, classification, and prognosis of chronic kidney disease: a KDIGO Controversies Conference report.
      • Wetzels J.F.
      • Kiemeney L.A.
      • Swinkels D.W.
      • Willems H.L.
      • den Heijer M.
      Age- and gender-specific reference values of estimated GFR in Caucasians: the Nijmegen Biomedical Study.
      CKD stage 5 (ESRD) is characterised by GFR below 15 ml/min per 1.73 m2 and includes two phases: the first one is treated conservatively without dialysis; when the second phase follows, the initiation of renal replacement therapy (RRT) in the form of dialysis or transplantation is required to sustain life.
      The incidence of CKD stage 5 refers to the number of patients with ESRD beginning RRT, thus failing to take into account patients not treated by RRT and underestimating the overall true incidence of ESRD. In the dialysis population, prevalence is a function of the incidence (new cases) and outcome (transplantation or death) rates of ESRD.

      2.1.1 Epidemiology of end stage renal disease

      2.1.1.1 Incidence

      The number of patients per year starting RRT has shown an exponential rise.
      • Port F.K.
      End-stage renal disease: magnitude of the problem, prognosis of future trends and possible solutions.
      Such a large number of CKD patients requiring dialysis may have three main causes: patient selection, competitive risks and a true increase in CKD incidence:
      1. Selection of patients for RRT: the steep increase in the incidence of older patients suggests that those very old and/or those affected by particularly severe comorbidities were not given access to dialysis in the first decades of RRT, compared with the more recent years.
      2. Competitive risks: a study suggested that the number of deaths where CKD is the underlying cause of death increased by 82% between 1990 (27th in the global death rank) and 2010 (18th in the global death rank).
      • Lozano R.
      • Naghavi M.
      • Foreman K.
      • Lim S.
      • Shibuya K.
      • Aboyans V.
      • et al.
      Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.
      A high risk of death exists even in patients in the early stages of CKD, with many individuals in stages 3 and 4 dying before starting RRT.
      • Keith D.S.
      • Nichols G.A.
      • Gullion C.M.
      • Brown J.B.
      • Smith D.H.
      Longitudinal follow-up and outcomes among a population with chronic kidney disease in a large managed care organization.
      • Go A.S.
      • Chertow G.M.
      • Fan D.
      • McCulloch C.E.
      • Hsu C.Y.
      Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization.
      In fact, a reduced GFR is considered one of the most important risk factors for coronary heart disease.
      • Sarnak M.J.
      • Levey A.S.
      • Schoolwerth A.C.
      • Coresh J.
      • Culleton B.
      • Hamm L.L.
      • et al.
      Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention.
      Substantial improvements in the treatment of cardiac diseases and in survival have occurred in recent decades and this has allowed many patients to survive in the more advanced CKD stages and to require RRT.
      3. The true increase in CKD incidence: it may also be possible that the increased incidence of ESRD reflects increases in the underlying prevalence of CKD. The Framingham Heart Study has shown that the incidence of type 2 diabetes has doubled from the 1970s to the 1990s.
      • Fox C.S.
      • Pencina M.J.
      • Meigs J.B.
      • Vasan R.S.
      • Levitzky Y.S.
      • D'Agostino Sr., R.B.
      Trends in the incidence of type 2 diabetes mellitus from the 1970s to the 1990s: the Framingham Heart Study.
      Furthermore, potentially nephrotoxic drugs, such as non-steroidal anti-inflammatory drugs, antibiotics and chemotherapy agents are used more commonly. Finally, reduced mortality from cardiovascular diseases and cancer may be associated with an increase in the number of patients reaching ESRD.

      2.1.1.2 Prevalence

      Data related to the prevalence of CKD stage 5 are lacking, except for those of registries of ESRD patients treated by dialysis or transplantation. In the USA, of the 547,982 prevalent ESRD patients in 2008, 70 percent were being treated by dialysis while 30 percent had a functioning kidney transplant. In 2008 alone, 112,476 patients entered the US ESRD program. Adjusted rates for incident and prevalent ESRD are 351 and 1,699 cases per million population, respectively. Diabetes and hypertension account for 44% and 27.9% of all causes of incident ESRD, respectively.
      • United States Renal Data System
      USRDS 2010 annual data report: Atlas of chronic kidney disease and end-stage renal disease in the United States.
      The prevalence of a disease increases if the patient survival increases with a constant incidence rate or if the incidence rate increases with a constant survival rate. Thus the rising prevalence of treated ESRD can be attributed either to the increase in the number of patients who start RRT each year and/or to the increased survival of patients with ESRD. Since the incidence rates of treated ESRD have flattened in recent years, longer lifespans of prevalent ESRD patients may partially explain the steady growth of this population.
      • United States Renal Data System
      USRDS 2010 annual data report: Atlas of chronic kidney disease and end-stage renal disease in the United States.
      Continuing global efforts should be made in the prevention and treatment of acute and especially chronic conditions potentially leading to ESRD, in particular diabetes and hypertension.

      2.2 Demographics of end stage renal disease

      The global epidemiology of ESRD is heterogeneous and influenced by several factors. Consequently, the incidence and prevalence of ESRD are markedly different from country to country (Table 4). Disparities in the incidence and prevalence of ESRD within and between developed countries reflect racial and ethnic diversities as well as their impact on the prevalence of diabetes and hypertension in respective countries and communities. The incidence is higher among African and Native Americans and aboriginal people of Australia and New Zealand.
      K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification.
      • United States Renal Data System
      USRDS 2010 annual data report: Atlas of chronic kidney disease and end-stage renal disease in the United States.
      • Bottalico D.
      • Port F.K.
      • Schena F.P.
      Outcomes in dialysis: a global assessment.
      • ERA-EDTA
      Registry: ERA-EDTA registry 2005 annual report.
      • Canadian Organ Replacement Register Annual Report 2011
      Treatment of end-stage organ failure in Canada, 2000 to 2009.
      • Polkinghorne K.R.
      • Dent H.
      • Gulyani A.
      • Hurst K.
      • McDonald S.P.
      Haemodialysis in ANZDATA registry report 2011.
      Diabetes as a cause of ESRD is particularly frequent in these populations. Disparities with developing countries are likely to reflect availability of and access to RRT in low and middle income economies rather than a lower incidence of CKD. Diabetes as the primary cause of CKD affects a particularly high percentage of incident patients in the USA.
      Table 4Global incidence and prevalence of RRT (per million population) in different parts of the world in 2002 and 2006.
      Source: References
      • United States Renal Data System
      USRDS 2010 annual data report: Atlas of chronic kidney disease and end-stage renal disease in the United States.
      • ERA-EDTA
      Registry: ERA-EDTA registry 2005 annual report.
      • Polkinghorne K.R.
      • Dent H.
      • Gulyani A.
      • Hurst K.
      • McDonald S.P.
      Haemodialysis in ANZDATA registry report 2011.
      • Castledine C.
      • van Schalkwyk D.
      • Feest T.
      UK renal registry 13th annual report (December 2010): chapter 7: the relationship between the type of vascular access used and survival in UK RRT patients in 2006.
      IncidencePrevalence
      2002200620022006
      UNITED STATES3333601,4461,626
      Caucasians2552791,0601,194
      African Americans9821,0104,4675,004
      Native Americans5144892,5692,691
      Asians3443881,5711,831
      Hispanics4814811,9911,991
      AUSTRALIA94115658778
      Aboriginals, Torres Strait islanders3934411,9042,070
      EUROPE129129770770
      United Kingdom101113626725
      France123140898957
      Germany174140918957
      Italy1421338641,010
      Spain126132950991
      JAPAN2622751,7261,956
      The elderly are a substantial and growing fraction of the RRT population worldwide, reaching 25–30% in most ESRD registries.
      • United States Renal Data System
      USRDS 2010 annual data report: Atlas of chronic kidney disease and end-stage renal disease in the United States.
      • ERA-EDTA
      Registry: ERA-EDTA registry 2005 annual report.
      In the United States, the proportion of patients >65 years of age starting dialysis has increased by nearly 10% annually, representing an overall increase of 57% between 1996 and 2003.
      • United States Renal Data System
      USRDS 2010 annual data report: Atlas of chronic kidney disease and end-stage renal disease in the United States.
      In Canada, from 1990 until 2001, the incident dialysis rate among patients aged 75 and older increased 74%.
      • Canadian Organ Replacement Register Annual Report 2011
      Treatment of end-stage organ failure in Canada, 2000 to 2009.
      Researchers have speculated that more liberal acceptance of the very elderly (≥80 years) into dialysis programs has contributed to the increase in patients with ESRD.
      • Muntner P.
      • Coresh J.
      • Powe N.R.
      • Klag M.J.
      The contribution of increased diabetes prevalence and improved myocardial infarction and stroke survival to the increase in treated end-stage renal disease.
      • Port F.K.
      The end-stage renal disease program: trends over the past 18 years.
      CKD is expected to be a major 21st century medical challenge. In developing nations, the growing prevalence of CKD has severe implications on health and economic output.
      • Nugent R.A.
      • Fathima S.F.
      • Feigl A.B.
      • Chyung D.
      The burden of chronic kidney disease on developing nations: a 21st century challenge in global health.
      The rapid rise of common risk factors such as diabetes, hypertension and obesity, especially among the poor, will result in even greater and more profound burdens that developing nations are not equipped to handle.
      • Nugent R.A.
      • Fathima S.F.
      • Feigl A.B.
      • Chyung D.
      The burden of chronic kidney disease on developing nations: a 21st century challenge in global health.

      2.3 Epidemiology of vascular access for dialysis

      Large differences in VA exist between Europe, Canada, and the United States, even after adjustment for patient characteristics.
      • Gallieni M.
      • Saxena R.
      • Davidson I.
      Dialysis access in Europe and North America: are we on the same path?.
      VA care is characterised by similar issues, but with a different magnitude. Obesity, type 2 diabetes, and peripheral vascular disease, independent predictors of CVC use, are growing problems globally, which could lead to more difficulties in native AVF creation and survival.
      Nevertheless, in the USA following the establishment of the Fistula First Initiative, AVF use among prevalent HD patients increased steadily from 34.1% in December 2003 to 60.6% in April 2012.

      Arteriovenous fistula first website [20.09.2016]. Available from: www.fistulafirst.org.

      In incident patients, VA statistics at the start of chronic HD in 2009 were: AVF in use 14.3%; AVG in use 3.2%; CVC in use 81.8%; AVF maturing 15.8%; AVG maturing 1.9%. Figures were similar in 2014.

      United States renal data system annual data report; end-stage renal disease in the United States; chapter 4: vascular access 2015 [20.09.2016]. Available from: http://www.usrds.org/2015/view.

      International data from DOPPS (dialysis outcomes and practice patterns study) has shown large variations in VA practice
      • Ethier J.
      • Mendelssohn D.C.
      • Elder S.J.
      • Hasegawa T.
      • Akizawa T.
      • Akiba T.
      • et al.
      Vascular access use and outcomes: an international perspective from the Dialysis Outcomes and Practice Patterns Study.
      and greater mortality risks have been seen for HD patients dialysing with a catheter, while patients with an usable AVF have the lowest risk.
      • Ravani P.
      • Palmer S.C.
      • Oliver M.J.
      • Quinn R.R.
      • MacRae J.M.
      • Tai D.J.
      • et al.
      Associations between hemodialysis access type and clinical outcomes: a systematic review.
      International trends in VA practices have been observed within the DOPPS from 1996 to 2007.
      • Ethier J.
      • Mendelssohn D.C.
      • Elder S.J.
      • Hasegawa T.
      • Akizawa T.
      • Akiba T.
      • et al.
      Vascular access use and outcomes: an international perspective from the Dialysis Outcomes and Practice Patterns Study.
      Between 2005 and 2007, a native AVF was used by 67–91% of prevalent patients in Japan, Italy, Germany, France, Spain, the UK, Australia and New Zealand, and 50–59% in Belgium, Sweden and Canada. From 1996 to 2007, AVF use rose from 24% to 47% in the USA but declined in Italy, Germany and Spain. Across three phases of data collection, patients were consistently less likely to use an AVF versus other VA types if female, of greater age, having greater body mass index, diabetes, and peripheral vascular disease. In addition, countries with a greater prevalence of diabetes in HD patients had a significantly lower percentage of patients using an AVF. Despite poorer outcomes for CVCs, catheter use rose 1.5–3 fold among prevalent patients in many countries from 1996 to 2007, even among non-diabetic patients 18–70 years old. Furthermore, 58–73% of incident patients used a CVC for the initiation of dialysis in five countries despite 60–79% of patients having been seen by a nephrologist more than 4 months prior to ESRD. The median time from referral to VA creation varied from 5–6 days in Italy, Japan and Germany to 40–43 days in the UK and Canada. Surgery waiting time, along with time from VA creation to first cannulation, significantly affected the possibility of starting HD with a permanent VA.
      • Ethier J.
      • Mendelssohn D.C.
      • Elder S.J.
      • Hasegawa T.
      • Akizawa T.
      • Akiba T.
      • et al.
      Vascular access use and outcomes: an international perspective from the Dialysis Outcomes and Practice Patterns Study.
      Patient preference for a CVC varied across countries, ranging from 1% of HD patients in Japan and 18% in the United States, to 42%–44% in Belgium and Canada.
      • Fissell R.B.
      • Fuller D.S.
      • Morgenstern H.
      • Gillespie B.W.
      • Mendelssohn D.C.
      • Rayner H.C.
      • et al.
      Hemodialysis patient preference for type of vascular access: variation and predictors across countries in the DOPPS.
      Preference for a CVC was positively associated with age, female sex, and former or current catheter use. The observed considerable variation in patient preference for VA suggests that patient preference may be influenced by socio-cultural factors and thus could be modifiable.
      The use of CVCs carries a significant risk of serious complications. Lately, in non-renal patients the peripherally inserted central venous catheter (PICC) has gained in popularity due to presumed advantages over other CVCs. However, the use of PICC lines is not indicated in CKD patients because of subsequent adverse VA outcomes, i.e. a lower likelihood (15%–19%) of having a functioning fistula or graft.
      • McGill R.L.
      • Ruthazer R.
      • Meyer K.B.
      • Miskulin D.C.
      • Weiner D.E.
      Peripherally inserted central catheters and hemodialysis outcomes.
      Early referral of ESRD patients to the nephrologist is strongly recommended. This approach may minimise the use of catheters and reduce catheter related morbidity and the need for hospitalisation.
      • Davidson I.
      • Gallieni M.
      • Saxena R.
      • Dolmatch B.
      A patient centered decision making dialysis access algorithm.
      Early referral to the nephrologist is also required for interventions to delay progression of renal damage and to correct hypertension, anaemia and the metabolic effects of renal failure, discussion of renal replacement treatment options, including living related transplantation and peritoneal dialysis, and psychological preparation for dialysis.
      • Jungers P.
      • Massy Z.A.
      • Nguyen-Khoa T.
      • Choukroun G.
      • Robino C.
      • Fakhouri F.
      • et al.
      Longer duration of predialysis nephrological care is associated with improved long-term survival of dialysis patients.
      When haemodialysis is the choice, time from referral to surgery for VA creation should be as short as possible.
      • Ethier J.
      • Mendelssohn D.C.
      • Elder S.J.
      • Hasegawa T.
      • Akizawa T.
      • Akiba T.
      • et al.
      Vascular access use and outcomes: an international perspective from the Dialysis Outcomes and Practice Patterns Study.

      3. Clinical decision making

      3.1 Choice of type of vascular access

      Successful HD treatment is only possible with a well functioning VA. The ideal VA should allow cannulation using two needles, deliver a minimum blood flow of at least 300 ml/min through the artificial kidney, is resistant to infection and thrombosis and should have minimum adverse events. The first option for the construction of a VA is the creation of an autogenous AVF. Secondary and tertiary options are prosthetic AVG and CVCs. The reason for creating autogenous AVFs is that observational studies show a lower incidence of post-operative complications and fewer endovascular and surgical revisions for AVF failure in comparison to AVGs.
      • Murad M.H.
      • Elamin M.B.
      • Sidawy A.N.
      • Malaga G.
      • Rizvi A.Z.
      • Flynn D.N.
      • et al.
      Autogenous versus prosthetic vascular access for hemodialysis: a systematic review and meta-analysis.
      • Almasri J.
      • Alsawas M.
      • Mainou M.
      • Mustafa R.A.
      • Wang Z.
      • Woo K.
      • et al.
      Outcomes of vascular access for hemodialysis: A systematic review and meta-analysis.
      • Al-Jaishi A.A.
      • Liu A.R.
      • Lok C.E.
      • Zhang J.C.
      • Moist L.M.
      Complications of the arteriovenous fistula: a systematic review.
      In addition, the use of CVCs results in a significantly higher morbidity and mortality rate. The risk of hospitalisation for VA related reasons and particularly for infection is highest for patients on HD with a catheter at initiation and throughout follow-up.
      • Ng L.J.
      • Chen F.
      • Pisoni R.L.
      • Krishnan M.
      • Mapes D.
      • Keen M.
      • et al.
      Hospitalization risks related to vascular access type among incident US hemodialysis patients.
      The principle of venous preservation dictates that the most distal AVF possible should usually be performed.
      • Gibbons C.P.
      Primary vascular access.
      The strategy is to start HD in incident patients with a distal autogenous AVF preferably in the non-dominant upper extremity. In cases of a failed distal VA a more proximally located AVF can be performed.

      3.2 Timing of referral for vascular access surgery

      Timely patient referral for VA creation is of importance for the outcome of the VA. Early referral results in more well functioning autogenous AVFs,
      • Ravani P.
      • Brunori G.
      • Mandolfo S.
      • Cancarini G.
      • Imbasciati E.
      • Marcelli D.
      • et al.
      Cardiovascular comorbidity and late referral impact arteriovenous fistula survival: a prospective multicenter study.
      while late referral results in a greater chance of AVF non-maturation and the need for a CVC for HD.
      • Avorn J.
      • Winkelmayer W.C.
      • Bohn R.L.
      • Levin R.
      • Glynn R.J.
      • Levy E.
      • et al.
      Delayed nephrologist referral and inadequate vascular access in patients with advanced chronic kidney failure.
      • Roubicek C.
      • Brunet P.
      • Huiart L.
      • Thirion X.
      • Leonetti F.
      • Dussol B.
      • et al.
      Timing of nephrology referral: influence on mortality and morbidity.
      • Tordoir J.
      • Canaud B.
      • Haage P.
      • Konner K.
      • Basci A.
      • Fouque D.
      • et al.
      EBPG on vascular access.
      Moreover timely referral slows eGFR decline.
      • Sumida K.
      • Molnar M.Z.
      • Potukuchi P.K.
      • Thomas F.
      • Lu J.L.
      • Ravel V.A.
      • et al.
      Association between vascular access creation and deceleration of estimated glomerular filtration rate decline in late-stage chronic kidney disease patients transitioning to end-stage renal disease.
      Also, HD initiation with a CVC and a long AVF maturation time, results in poorer long-term AVF patency rates. The same factors that predict worse primary AVF survival are also associated with greater risk of final failure. The presence of cardiovascular disease, use of catheters at HD initiation, and early cannulation are independent predictors of final failure. A short time to cannulation is associated with the greatest risk of final failure.
      • Ravani P.
      • Brunori G.
      • Mandolfo S.
      • Cancarini G.
      • Imbasciati E.
      • Marcelli D.
      • et al.
      Cardiovascular comorbidity and late referral impact arteriovenous fistula survival: a prospective multicenter study.
      (Figure 2, Figure 3) Frequent (every 3 months) pre-nephrology visits (PNV) are related to improved patient survival during the first year after initiation of HD, indicating the possible survival benefit with increased attention to PNV, particularly for elderly and diabetic patients.
      • Hasegawa T.
      • Bragg-Gresham J.L.
      • Yamazaki S.
      • Fukuhara S.
      • Akizawa T.
      • Kleophas W.
      • et al.
      Greater first-year survival on hemodialysis in facilities in which patients are provided earlier and more frequent pre-nephrology visits.
      • de Jager D.J.
      • Voormolen N.
      • Krediet R.T.
      • Dekker F.W.
      • Boeschoten E.W.
      • Grootendorst D.C.
      Association between time of referral and survival in the first year of dialysis in diabetics and the elderly.
      From the DOPPS data, significant differences between European countries in referral type and time of VA creation have been reported. Planning of VA surgery varies between <5 days (Italy) to >42 days (UK) after referral to the VA surgeon.
      • Ethier J.
      • Mendelssohn D.C.
      • Elder S.J.
      • Hasegawa T.
      • Akizawa T.
      • Akiba T.
      • et al.
      Vascular access use and outcomes: an international perspective from the Dialysis Outcomes and Practice Patterns Study.
      Figure thumbnail gr2
      Figure 2Kaplan-Meier curves of time to AVF failure (primary patency from first cannulation) by use of catheters (CVC) at the initiation of HD (left) and by the time to maturation in days (right). Reproduced with permission from Ravani et al.
      • Ravani P.
      • Brunori G.
      • Mandolfo S.
      • Cancarini G.
      • Imbasciati E.
      • Marcelli D.
      • et al.
      Cardiovascular comorbidity and late referral impact arteriovenous fistula survival: a prospective multicenter study.
      Figure thumbnail gr3
      Figure 3Risk factors associated with primary and secondary access failure. Hazard ratios plotted using a logarithmic scale. Reproduced with permission from Ravani et al.
      • Ravani P.
      • Brunori G.
      • Mandolfo S.
      • Cancarini G.
      • Imbasciati E.
      • Marcelli D.
      • et al.
      Cardiovascular comorbidity and late referral impact arteriovenous fistula survival: a prospective multicenter study.
      The knowledge and experience of the VA surgeon is of importance in creating predominantly AVFs and has a major impact on the outcome of surgery.
      • Prischl F.C.
      • Kirchgatterer A.
      • Brandstatter E.
      • Wallner M.
      • Baldinger C.
      • Roithinger F.X.
      • et al.
      Parameters of prognostic relevance to the patency of vascular access in hemodialysis patients.
      • Saran R.
      • Elder S.J.
      • Goodkin D.A.
      • Akiba T.
      • Ethier J.
      • Rayner H.C.
      • et al.
      Enhanced training in vascular access creation predicts arteriovenous fistula placement and patency in hemodialysis patients: results from the Dialysis Outcomes and Practice Patterns Study.
      However, there remain large regional differences between hospitals, concerning the number of autogenous AVFs created and the probability of successful maturation.
      • Huijbregts H.J.
      • Bots M.L.
      • Moll F.L.
      • Blankestijn P.J.
      Hospital specific aspects predominantly determine primary failure of hemodialysis arteriovenous fistulas.

      3.3 Selection of vascular access modality

      3.3.1 Primary option for vascular access – autogenous arteriovenous fistula

      The radiocephalic AVF (RCAVF) at the level of the wrist is the first choice for VA creation. When successfully matured, the RCAVF can function for years with a minimum of complications, revisions and hospital admissions. The RCAVF is preferentially created in the non-dominant arm, but the dominant extremity may be chosen if the vessels in the non-dominant arm are unsuitable. The indication to perform a wrist RCAVF depends on the outcome of physical examination (inspection and palpation of distal veins and arteries) and additional ultrasound examination. A minimum internal vessel diameter for both radial artery and cephalic vein of 2.0 mm using a proximal tourniquet is considered to be adequate for successful fistula creation and maturation. For brachiocephalic (BCAVF) and brachiobasilic (BBAVF) AVFs a minimum arterial and venous diameter of 3 mm is sufficient.
      Major disadvantages are the risk of early thrombosis and non-maturation and, ultimately, access failure. A meta-analysis showed a 17% mean early failure rate.
      • Rooijens P.P.
      • Tordoir J.H.
      • Stijnen T.
      • Burgmans J.P.
      • Smet de A.A.
      • Yo T.I.
      Radiocephalic wrist arteriovenous fistula for hemodialysis: meta-analysis indicates a high primary failure rate.
      However, recent studies have shown higher failure rates of up to 46%, with one year patencies from 52% to 83% (Table 5). An elderly dialysis population with concurrent comorbidities and poor upper extremity vessels is the reason for these high early failure rates.
      • Huijbregts H.J.
      • Bots M.L.
      • Wittens C.H.
      • Schrama Y.C.
      • Moll F.L.
      • Blankestijn P.J.
      Hemodialysis arteriovenous fistula patency revisited: results of a prospective, multicenter initiative.
      Table 5Early failure and one year secondary patency rate of the radiocephalic AVF.
      ReferenceNo. RCAVFEarly failure (%)Secondary patency (%)
      Silva et al.
      • Silva Jr., M.B.
      • Hobson 2nd, R.W.
      • Pappas P.J.
      • Jamil Z.
      • Araki C.T.
      • Goldberg M.C.
      • et al.
      A strategy for increasing use of autogenous hemodialysis access procedures: impact of preoperative noninvasive evaluation.
      1082683
      Golledge et al.
      • Golledge J.
      • Smith C.J.
      • Emery J.
      • Farrington K.
      • Thompson H.H.
      Outcome of primary radiocephalic fistula for haemodialysis.
      1071869
      Wolowczyk et al.
      • Wolowczyk L.
      • Williams A.J.
      • Donovan K.L.
      • Gibbons C.P.
      The snuffbox arteriovenous fistula for vascular access.
      2082065
      Gibson et al.
      • Gibson K.D.
      • Gillen D.L.
      • Caps M.T.
      • Kohler T.R.
      • Sherrard D.J.
      • Stehman-Breen C.O.
      Vascular access survival and incidence of revisions: a comparison of prosthetic grafts, simple autogenous fistulas, and venous transposition fistulas from the United States Renal Data System Dialysis Morbidity and Mortality Study.
      1302356
      Allon et al.
      • Allon M.
      • Lockhart M.E.
      • Lilly R.Z.
      • Gallichio M.H.
      • Young C.J.
      • Barker J.
      • et al.
      Effect of preoperative sonographic mapping on vascular access outcomes in hemodialysis patients.
      1394642
      Dixon et al.
      • Dixon B.S.
      • Novak L.
      • Fangman J.
      Hemodialysis vascular access survival: upper-arm native arteriovenous fistula.
      2053053
      Ravani et al.
      • Ravani P.
      • Marcelli D.
      • Malberti F.
      Vascular access surgery managed by renal physicians: the choice of native arteriovenous fistulas for hemodialysis.
      197571
      Rooijens et al.
      • Rooijens P.P.
      • Burgmans J.P.
      • Yo T.I.
      • Hop W.C.
      • de Smet A.A.
      • van den Dorpel M.A.
      • et al.
      Autogenous radial-cephalic or prosthetic brachial-antecubital forearm loop AVF in patients with compromised vessels? A randomized, multicenter study of the patency of primary hemodialysis access.
      864152
      Biuckians et al.
      • Biuckians A.
      • Scott E.C.
      • Meier G.H.
      • Panneton J.M.
      • Glickman M.H.
      The natural history of autologous fistulas as first-time dialysis access in the KDOQI era.
      803763
      Huijbregts et al.
      • Huijbregts H.J.
      • Bots M.L.
      • Wittens C.H.
      • Schrama Y.C.
      • Moll F.L.
      • Blankestijn P.J.
      Hemodialysis arteriovenous fistula patency revisited: results of a prospective, multicenter initiative.
      6493070
      When a wrist RCAVF is not possible or has failed, a more proximally located AVF in the forearm, antecubital region or upper arm may be performed. These accesses are called mid-forearm, brachial/radial-deep perforating vein,
      • Gracz K.C.
      • Ing T.S.
      • Soung L.S.
      • Armbruster K.F.
      • Seim S.K.
      • Merkel F.K.
      Proximal forearm fistula for maintenance hemodialysis.
      brachial-median cubital vein, BCAVF and BBAVF. Brachial artery based AVFs deliver a high access flow which favours high HD flows, but may result in reduced distal arterial perfusion and cardiac overload.
      • van Hoek F.
      • Scheltinga M.R.
      • Kouwenberg I.
      • Moret K.E.
      • Beerenhout C.H.
      • Tordoir J.H.
      Steal in hemodialysis patients depends on type of vascular access.
      These types of AVFs show good one year patencies (Table 6, Table 7) with a low incidence of thrombosis (0.2 events per patient/year) and infection (2%).
      Table 6Early failure (within one month of access creation) and one year secondary patency rate of brachiocephalic AVF (including brachiocephalic/perforating vein AVF).
      ReferenceNo. BCAVFEarly failure (%)Secondary patency (%)
      Murphy et al.
      • Murphy G.J.
      • Saunders R.
      • Metcalfe M.
      • Nicholson M.L.
      Elbow fistulas using autogeneous vein: patency rates and results of revision.
      2081675
      Zeebregts et al.
      • Zeebregts C.J.
      • Tielliu I.F.
      • Hulsebos R.G.
      • de Bruin C.
      • Verhoeven E.L.
      • Huisman R.M.
      • et al.
      Determinants of failure of brachiocephalic elbow fistulas for haemodialysis.
      1001179
      Lok et al.
      • Lok C.E.
      • Oliver M.J.
      • Su J.
      • Bhola C.
      • Hannigan N.
      • Jassal S.V.
      Arteriovenous fistula outcomes in the era of the elderly dialysis population.
      186978
      Woo et al.
      • Woo K.
      • Farber A.
      • Doros G.
      • Killeen K.
      • Kohanzadeh S.
      Evaluation of the efficacy of the transposed upper arm arteriovenous fistula: a single institutional review of 190 basilic and cephalic vein transposition procedures.
      711266
      Koksoy et al.
      • Koksoy C.
      • Demirci R.K.
      • Balci D.
      • Solak T.
      • Kose S.K.
      Brachiobasilic versus brachiocephalic arteriovenous fistula: a prospective randomized study.
      50887
      Palmes et al.
      • Palmes D.
      • Kebschull L.
      • Schaefer R.M.
      • Pelster F.
      • Konner K.
      Perforating vein fistula is superior to forearm fistula in elderly haemodialysis patients with diabetes and arterial hypertension.
      55989
      Ayez et al.
      • Ayez N.
      • van Houten V.A.
      • de Smet A.A.
      • van Well A.M.
      • Akkersdijk G.P.
      • van de Ven P.J.
      • et al.
      The basilic vein and the cephalic vein perform equally in upper arm arteriovenous fistulae.
      87883
      Table 7Early failure (within one month of access creation) and one year secondary patency rate of brachiobasilic AVF.
      ReferenceNo. BBAVFEarly failure (%)Secondary patency (%)
      Murphy et al.
      • Murphy G.J.
      • Saunders R.
      • Metcalfe M.
      • Nicholson M.L.
      Elbow fistulas using autogeneous vein: patency rates and results of revision.
      74375
      Segal et al.
      • Segal J.H.
      • Kayler L.K.
      • Henke P.
      • Merion R.M.
      • Leavey S.
      • Campbell Jr., D.A.
      Vascular access outcomes using the transposed basilic vein arteriovenous fistula.
      992364
      Wolford et al.
      • Wolford H.Y.
      • Hsu J.
      • Rhodes J.M.
      • Shortell C.K.
      • Davies M.G.
      • Bakhru A.
      • et al.
      Outcome after autogenous brachial-basilic upper arm transpositions in the post-National Kidney Foundation Dialysis Outcomes Quality Initiative era.
      1002047
      Arroyo et al.
      • Arroyo M.R.
      • Sideman M.J.
      • Spergel L.
      • Jennings W.C.
      Primary and staged transposition arteriovenous fistulas.
      65888
      Keuter et al.
      • Keuter X.H.
      • De Smet A.A.
      • Kessels A.G.
      • van der Sande F.M.
      • Welten R.J.
      • Tordoir J.H.
      A randomized multicenter study of the outcome of brachial-basilic arteriovenous fistula and prosthetic brachial-antecubital forearm loop as vascular access for hemodialysis.
      52289
      Koksoy et al.
      • Koksoy C.
      • Demirci R.K.
      • Balci D.
      • Solak T.
      • Kose S.K.
      Brachiobasilic versus brachiocephalic arteriovenous fistula: a prospective randomized study.
      50888
      Field et al.
      • Field M.
      • Van Dellen D.
      • Mak D.
      • Winter H.
      • Hamsho A.
      • Mellor S.
      • et al.
      The brachiobasilic arteriovenous fistula: effect of patient variables.
      1401969
      Ayez et al.
      • Ayez N.
      • van Houten V.A.
      • de Smet A.A.
      • van Well A.M.
      • Akkersdijk G.P.
      • van de Ven P.J.
      • et al.
      The basilic vein and the cephalic vein perform equally in upper arm arteriovenous fistulae.
      86673
      If direct arteriovenous anastomoses are impossible, vein transposition/translocation can be performed, with redirection of a suitable vein to an available artery (forearm radial/ulnar-basilic AVF) or GSV harvesting from the leg and subsequent implantation between an arm artery and vein (see Chapter 8).
      A basilic vein transposition (BVT) in the upper arm is a good choice when RCAVFs or BCAVFs have failed or are not feasible. BBAVFs can be performed in either one or two stage operations.

      3.3.1.1 Patient variables and outcome of vascular access

      Various studies have shown the important influence of patient variables on choice and outcome of VA. Age and diabetes mellitus negatively influence fistula maturation and increase the risk of AVF failure.
      • Lin S.L.
      • Huang C.H.
      • Chen H.S.
      • Hsu W.A.
      • Yen C.J.
      • Yen T.S.
      Effects of age and diabetes on blood flow rate and primary outcome of newly created hemodialysis arteriovenous fistulas.
      A systematic review of the literature showed a tendency towards an increased risk of deep vein thrombosis and a decreased risk of catheter occlusion with a PICC.
      • Johansson E.
      • Hammarskjold F.
      • Lundberg D.
      • Arnlind M.H.
      Advantages and disadvantages of peripherally inserted central venous catheters (PICC) compared to other central venous lines: a systematic review of the literature.
      An anatomical region at high risk of thrombosis is the antecubital fossa. Elbow veins represent a valuable source for the creation of a VA for HD, especially in obese patients, elderly patients, diabetics and patients affected by peripheral artery disease.
      • Lomonte C.
      • Basile C.
      On the phenomenology of the perforating vein of the elbow.
      Such veins should be preserved (see Recommendation 14, Chapter 5).
      • Tordoir J.
      • Canaud B.
      • Haage P.
      • Konner K.
      • Basci A.
      • Fouque D.
      • et al.
      EBPG on vascular access.
      Women usually have smaller vessels than men, which may result in poorer maturation and lower long-term patency. Some studies show that females need more VA revisions and the creation of more AVGs,
      • Gibson K.D.
      • Gillen D.L.
      • Caps M.T.
      • Kohler T.R.
      • Sherrard D.J.
      • Stehman-Breen C.O.
      Vascular access survival and incidence of revisions: a comparison of prosthetic grafts, simple autogenous fistulas, and venous transposition fistulas from the United States Renal Data System Dialysis Morbidity and Mortality Study.
      • Enzler M.A.
      • Rajmon T.
      • Lachat M.
      • Largiader F.
      Long-term function of vascular access for hemodialysis.
      • Fisher C.M.
      • Neale M.L.
      Outcome of surgery for vascular access in patients commencing haemodialysis.
      • Hirth R.A.
      • Turenne M.N.
      • Woods J.D.
      • Young E.W.
      • Port F.K.
      • Pauly M.V.
      • et al.
      Predictors of type of vascular access in hemodialysis patients.
      • Kalman P.G.
      • Pope M.
      • Bhola C.
      • Richardson R.
      • Sniderman K.W.
      A practical approach to vascular access for hemodialysis and predictors of success.
      • Polkinghorne K.R.
      • McDonald S.P.
      • Marshall M.R.
      • Atkins R.C.
      • Kerr P.G.
      Vascular access practice patterns in the New Zealand hemodialysis population.
      • Rodriguez J.A.
      • Lopez J.
      • Cleries M.
      • Vela E.
      Vascular access for haemodialysis–an epidemiological study of the Catalan Renal Registry.
      while others, including a meta-analysis, could not demonstrate any significant differences in vessel diameters and the probability of maturation between men and women.
      • Rooijens P.P.
      • Tordoir J.H.
      • Stijnen T.
      • Burgmans J.P.
      • Smet de A.A.
      • Yo T.I.
      Radiocephalic wrist arteriovenous fistula for hemodialysis: meta-analysis indicates a high primary failure rate.
      • Caplin N.
      • Sedlacek M.
      • Teodorescu V.
      • Falk A.
      • Uribarri J.
      Venous access: women are equal.
      Diabetes mellitus and arteriosclerosis are the most important causes of renal failure and HD treatment and can have a negative influence on successful use of the VA.
      • Hirth R.A.
      • Turenne M.N.
      • Woods J.D.
      • Young E.W.
      • Port F.K.
      • Pauly M.V.
      • et al.
      Predictors of type of vascular access in hemodialysis patients.
      Other variables that influence fistula use are: lower extremity atherosclerotic disease (LEAD), race and obesity.
      • Allon M.
      • Ornt D.B.
      • Schwab S.J.
      • Rasmussen C.
      • Delmez J.A.
      • Greene T.
      • et al.
      Factors associated with the prevalence of arteriovenous fistulas in hemodialysis patients in the HEMO study. Hemodialysis (HEMO) Study Group.
      Patients using calcium channel blockers, aspirin and ACE inhibitors, enjoy better AVF and AVG patency.
      • Saran R.
      • Dykstra D.M.
      • Wolfe R.A.
      • Gillespie B.
      • Held P.J.
      • Young E.W.
      Association between vascular access failure and the use of specific drugs: the Dialysis Outcomes and Practice Patterns Study (DOPPS).

      3.3.2 Secondary options for vascular access

      When there are no options for creating an autogenous AVF, an AVG VA with the implantation of synthetic (expanded polytetrafluoroethylene [ePTFE]; polyurethane; nanograft=electrospun ePTFE graft) or biological material (ovine graft/Omniflow®) can be created. ePTFE is frequently used as an AVG with reasonable short-term patency but long-term patency is hampered by thrombotic occlusions, due to stenoses caused by progressive neointimal proliferation. One and two year primary patency varies between 40–50% and 20–30%, respectively. The secondary patency varies from 70 to 90% (at one year) and 50 to 70% at two years. Multiple interventions to prevent and treat thrombosis are required to achieve these outcomes.
      • Garcia-Pajares R.
      • Polo J.R.
      • Flores A.
      • Gonzalez-Tabares E.
      • Solis J.V.
      Upper arm polytetrafluoroethylene grafts for dialysis access. Analysis of two different graft sizes: 6 mm and 6–8 mm.
      • Lenz B.J.
      • Veldenz H.C.
      • Dennis J.W.
      • Khansarinia S.
      • Atteberry L.R.
      A three-year follow-up on standard versus thin wall ePTFE grafts for hemodialysis.
      • Tordoir J.H.
      • Hofstra L.
      • Leunissen K.M.
      • Kitslaar P.J.
      Early experience with stretch polytetrafluoroethylene grafts for haemodialysis access surgery: results of a prospective randomised study.
      • Barron P.T.
      • Wellington J.L.
      • Lorimer J.W.
      • Cole C.W.
      • Moher D.
      A comparison between expanded polytetrafluoroethylene and plasma tetrafluoroethylene grafts for hemodialysis access.
      • Kaufman J.L.
      • Garb J.L.
      • Berman J.A.
      • Rhee S.W.
      • Norris M.A.
      • Friedmann P.
      A prospective comparison of two expanded polytetrafluoroethylene grafts for linear forearm hemodialysis access: does the manufacturer matter?.
      Elderly patients may benefit from the use of AVGs, because of the high primary autogenous AVF failure rate in these patients.
      • Lazarides M.K.
      • Georgiadis G.S.
      • Antoniou G.A.
      • Staramos D.N.
      A meta-analysis of dialysis access outcome in elderly patients.
      An important consideration for AVG use (in particular “early stick grafts”) might be the avoidance of CVCs with their inherent high risk of infection, in particular when (sub)acute HD treatment is necessary and AVF creation/maturation is problematic.

      3.3.3 Lower extremity vascular access

      The indications for lower extremity VA are bilateral central venous occlusive disease (CVOD) or inability to create access in the upper extremity. Primary options are autogenous GSV
      • Correa J.A.
      • de Abreu L.C.
      • Pires A.C.
      • Breda J.R.
      • Yamazaki Y.R.
      • Fioretti A.C.
      • et al.
      Saphenofemoral arteriovenous fistula as hemodialysis access.
      and FV transpositions,
      • Gradman W.S.
      • Laub J.
      • Cohen W.
      Femoral vein transposition for arteriovenous hemodialysis access: improved patient selection and intraoperative measures reduce postoperative ischemia.
      and prosthetic graft implantation. Thigh VAs have acceptable patency rates but the handicap of an increased risk of ischaemia and infection.
      • Geenen I.L.
      • Nyilas L.
      • Stephen M.S.
      • Makeham V.
      • White G.H.
      • Verran D.J.
      Prosthetic lower extremity hemodialysis access grafts have satisfactory patency despite a high incidence of infection.
      In a meta-analysis the results of femoral vein transpositions and AVGs are described. The one year primary and secondary patency was 83% and 48% and 93% and 69%, for FV transpositions and AVGs respectively. VA loss due to infection was primarily seen in AVGs (18% vs. 1.6%; p<.05). Ischaemia occurs more with lower extremity AVFs than AVGs (21% vs. 7.1%, p<.05).
      • Antoniou G.A.
      • Lazarides M.K.
      • Georgiadis G.S.
      • Sfyroeras G.S.
      • Nikolopoulos E.S.
      • Giannoukas A.D.
      Lower-extremity arteriovenous access for haemodialysis: a systematic review.
      In another study the outcome of 70 FV accesses was published with good results but with an 18% incidence of critical ischaemia, for which revision surgery was indicated.
      • Bourquelot P.
      • Rawa M.
      • Van Laere O.
      • Franco G.
      Long-term results of femoral vein transposition for autogenous arteriovenous hemodialysis access.

      3.3.4 Indications for a permanent catheter for vascular access

      Temporary CVCs are frequently used for acute HD or as bridging VA during fistula maturation and complications. Permanent tcCVCs may be indicated in patients with severe VA induced ischaemia, cardiac failure or limited life expectancy. Patients with PD peritonitis or waiting for a planned living related renal transplant can also be dialysed through a CVC for a limited period.
      The primary location for a CVC is the right internal jugular vein followed by the left jugular, femoral and subclavian veins as alternative insertion locations. Femoral and subclavian vein CVCs should only be used for short periods, because of the risk of infection and CVOD.
      HD via a CVC has increased in the USA, Canada and Europe, with a significantly greater morbidity and mortality risk due to infectious complications in comparison with the use of AVFs and AVGs (Fig. 4).
      • Polkinghorne K.R.
      • McDonald S.P.
      • Atkins R.C.
      • Kerr P.G.
      Vascular access and all-cause mortality: a propensity score analysis.
      • Perl J.
      • Wald R.
      • McFarlane P.
      • Bargman J.M.
      • Vonesh E.
      • Na Y.
      • et al.
      Hemodialysis vascular access modifies the association between dialysis modality and survival.
      Figure thumbnail gr4
      Figure 4Survival (%) of patients with peritoneal dialysis (PD) versus central venous catheters (HD-CVC) and arteriovenous fistulas/grafts (HD-AVF/AVG), adjusted on the basis of a stratified Cox proportional Hazards model stratified by HD-CVC, PD, and HD-AVF/AVG and adjusted for age, race, gender, era of dialysis initiation, end stage renal disease comorbidity index, primary renal diagnosis, serum albumin, eGFR, province of treatment, and late referral. Reproduced with permission from Perl et al.
      • Perl J.
      • Wald R.
      • McFarlane P.
      • Bargman J.M.
      • Vonesh E.
      • Na Y.
      • et al.
      Hemodialysis vascular access modifies the association between dialysis modality and survival.
      Tabled 1
      Recommendation 1ClassLevelRefs.
      Referral of chronic kidney disease patients to the nephrologist and/or surgeon for preparing vascular access is recommended when they reach stage 4 of chronic kidney disease (glomerular filtration rate<30 ml/min/1.73 m2), especially in cases of rapidly progressing nephropathy.IC
      • Tordoir J.
      • Canaud B.
      • Haage P.
      • Konner K.
      • Basci A.
      • Fouque D.
      • et al.
      EBPG on vascular access.
      ,
      • Ortega T.
      • Ortega F.
      • Diaz-Corte C.
      • Rebollo P.
      • Ma Baltar J.
      • Alvarez-Grande J.
      The timely construction of arteriovenous fistulae: a key to reducing morbidity and mortality and to improving cost management.
      Recommendation 2
      A permanent vascular access should be created 3–6 months before the expected start of haemodialysis treatment.IB
      • Ravani P.
      • Brunori G.
      • Mandolfo S.
      • Cancarini G.
      • Imbasciati E.
      • Marcelli D.
      • et al.
      Cardiovascular comorbidity and late referral impact arteriovenous fistula survival: a prospective multicenter study.
      ,
      • Roubicek C.
      • Brunet P.
      • Huiart L.
      • Thirion X.
      • Leonetti F.
      • Dussol B.
      • et al.
      Timing of nephrology referral: influence on mortality and morbidity.
      ,
      • Tordoir J.
      • Canaud B.
      • Haage P.
      • Konner K.
      • Basci A.
      • Fouque D.
      • et al.
      EBPG on vascular access.
      ,
      • Hasegawa T.
      • Bragg-Gresham J.L.
      • Yamazaki S.
      • Fukuhara S.
      • Akizawa T.
      • Kleophas W.
      • et al.
      Greater first-year survival on hemodialysis in facilities in which patients are provided earlier and more frequent pre-nephrology visits.
      ,
      • Ortega T.
      • Ortega F.
      • Diaz-Corte C.
      • Rebollo P.
      • Ma Baltar J.
      • Alvarez-Grande J.
      The timely construction of arteriovenous fistulae: a key to reducing morbidity and mortality and to improving cost management.
      Recommendation 3
      An autogenous arteriovenous fistula is recommended as the primary option for vascular access.IA
      • Murad M.H.
      • Elamin M.B.
      • Sidawy A.N.
      • Malaga G.
      • Rizvi A.Z.
      • Flynn D.N.
      • et al.
      Autogenous versus prosthetic vascular access for hemodialysis: a systematic review and meta-analysis.
      ,
      • Ng L.J.
      • Chen F.
      • Pisoni R.L.
      • Krishnan M.
      • Mapes D.
      • Keen M.
      • et al.
      Hospitalization risks related to vascular access type among incident US hemodialysis patients.
      Recommendation 4
      The radiocephalic arteriovenous fistula is recommended as the preferred vascular access.IB
      • Murad M.H.
      • Elamin M.B.
      • Sidawy A.N.
      • Malaga G.
      • Rizvi A.Z.
      • Flynn D.N.
      • et al.
      Autogenous versus prosthetic vascular access for hemodialysis: a systematic review and meta-analysis.
      ,
      • van Hoek F.
      • Scheltinga M.R.
      • Kouwenberg I.
      • Moret K.E.
      • Beerenhout C.H.
      • Tordoir J.H.
      Steal in hemodialysis patients depends on type of vascular access.
      Recommendation 5
      When vessel suitability is adequate, the non-dominant extremity should be considered as the preferred location for vascular access.IIaC
      Recommendation 6
      A lower extremity vascular access should be considered only when upper extremity access is impossible.IIaC
      • Gradman W.S.
      • Laub J.
      • Cohen W.
      Femoral vein transposition for arteriovenous hemodialysis access: improved patient selection and intraoperative measures reduce postoperative ischemia.
      ,
      • Antoniou G.A.
      • Lazarides M.K.
      • Georgiadis G.S.
      • Sfyroeras G.S.
      • Nikolopoulos E.S.
      • Giannoukas A.D.
      Lower-extremity arteriovenous access for haemodialysis: a systematic review.
      ,
      • Bourquelot P.
      • Rawa M.
      • Van Laere O.
      • Franco G.
      Long-term results of femoral vein transposition for autogenous arteriovenous hemodialysis access.
      Recommendation 7
      Tunnelled cuffed central venous catheters as a long standing haemodialysis modality should be considered when the creation of arteriovenous fistulas or grafts is impossible or in patients with limited life expectancy.IIaB
      • Polkinghorne K.R.
      • McDonald S.P.
      • Atkins R.C.
      • Kerr P.G.
      Vascular access and all-cause mortality: a propensity score analysis.
      ,
      • Perl J.
      • Wald R.
      • McFarlane P.
      • Bargman J.M.
      • Vonesh E.
      • Na Y.
      • et al.
      Hemodialysis vascular access modifies the association between dialysis modality and survival.

      4. Pre-operative imaging

      4.1 Pre-operative assessment

      Besides a detailed pre-operative history and physical examination, non-invasive ultrasound imaging plays an important role in VA selection. Pre-operative duplex ultrasound (DUS) enhances the success of creation and the outcome of autogenous AVFs.
      • Ferring M.
      • Claridge M.
      • Smith S.A.
      • Wilmink T.
      Routine preoperative vascular ultrasound improves patency and use of arteriovenous fistulas for hemodialysis: a randomized trial.
      In a randomised trial, a primary failure rate of 25% without pre-operative DUS was observed in comparison with a failure rate of 6% with DUS.
      • Mihmanli I.
      • Besirli K.
      • Kurugoglu S.
      • Atakir K.
      • Haider S.
      • Ogut G.
      • et al.
      Cephalic vein and hemodialysis fistula: surgeon's observation versus color Doppler ultrasonographic findings.
      Ultrasound venous mapping allows a precise evaluation of the depth of vascular structures
      • Vassalotti J.A.
      • Falk A.
      • Cohl E.D.
      • Uribarri J.
      • Teodorescu V.
      Obese and non-obese hemodialysis patients have a similar prevalence of functioning arteriovenous fistula using pre-operative vein mapping.
      and detects VA sites that may be missed by clinical examination alone. Similar results were shown in a meta-analysis.
      • Georgiadis G.S.
      • Charalampidis D.G.
      • Argyriou C.
      • Georgakarakos E.I.
      • Lazarides M.K.
      The necessity for routine pre-operative ultrasound mapping before arteriovenous fistula creation: a meta-analysis.
      DUS assessment can measure arterial diameters and flow as well as reveal stenotic segments especially where physical tests (poor radial pulse, unsuitable forearm veins) suggest impaired arterial inflow.
      • Brown P.W.
      Preoperative radiological assessment for vascular access.
      In addition, DUS identifies patients with inadequate vessels in specific VA locations. In a study of 211 consecutive patients DUS found that 50% of them had inadequate arterial inflow for distal RCAVF creation.
      • Goldstein L.J.
      • Gupta S.
      Use of the radial artery for hemodialysis access.
      DUS provides helpful information before AVF construction such as internal vessel diameters and internal venous lesions.
      • Malovrh M.
      Native arteriovenous fistula: preoperative evaluation.
      Currently, a minimum pre-operative internal diameter of 2.0 mm for both arteries and veins is recommended before RCAVF creation and a minimum of 4.0 mm for the outflow vein in the elbow for AVG implantation.
      • Tordoir J.
      • Canaud B.
      • Haage P.
      • Konner K.
      • Basci A.
      • Fouque D.
      • et al.
      EBPG on vascular access.
      Furthermore DUS provides important information for the planning of potential future AVF superficialisation.
      Digital subtraction angiography (DSA) is helpful in only a small group of selected patients with significant peripheral vascular disease and suspected proximal arterial stenosis. The pre-operative endovascular approach allows identification and treatment in one procedure. However, the risk of potential contrast induced nephropathy must be carefully considered if iodinated contrast is used.
      • Asif A.
      • Cherla G.
      • Merrill D.
      • Cipleu C.D.
      • Tawakol J.B.
      • Epstein D.L.
      • et al.
      Venous mapping using venography and the risk of radiocontrast-induced nephropathy.
      CE-MRA enables accurate pre-operative detection of upper extremity arterial and venous stenosis and occlusions.
      • Laissy J.P.
      • Fernandez P.
      • Karila-Cohen P.
      • Delmas V.
      • Dupuy E.
      • Chillon S.
      • et al.
      Upper limb vein anatomy before hemodialysis fistula creation: cross-sectional anatomy using MR venography.
      • Planken N.R.
      • Tordoir J.H.
      • Duijm L.E.
      • van den Bosch H.C.
      • van der Sande F.M.
      • Kooman J.P.
      • et al.
      Magnetic resonance angiographic assessment of upper extremity vessels prior to vascular access surgery: feasibility and accuracy.
      However, contrast enhanced magnetic resonance angiography (CE-MRA) is not recommended, since use of gadolinium is associated with the potential risk of a nephrogenic systemic fibrosis, especially in patients with severely impaired renal function.
      • Fraum T.J.
      • Ludwig D.R.
      • Bashir M.R.
      • Fowler K.J.
      Gadolinium-based contrast agents: A comprehensive risk assessment.
      • Grobner T.
      Gadolinium–a specific trigger for the development of nephrogenic fibrosing dermopathy and nephrogenic systemic fibrosis?.
      Promising preliminary results for the pre-operative visualisation of arterial and venous vascular structures with non-contrast enhanced MRA (NCE-MRA) are available.
      • Bode A.S.
      • Planken R.N.
      • Merkx M.A.
      • van der Sande F.M.
      • Geerts L.
      • Tordoir J.H.
      • et al.
      Feasibility of non-contrast-enhanced magnetic resonance angiography for imaging upper extremity vasculature prior to vascular access creation.
      Tabled 1
      Recommendation 8ClassLevelRefs
      Pre-operative ultrasonography of bilateral upper extremity arteries and veins is recommended in all patients when planning the creation of a vascular access.IA
      • Ferring M.
      • Claridge M.
      • Smith S.A.
      • Wilmink T.
      Routine preoperative vascular ultrasound improves patency and use of arteriovenous fistulas for hemodialysis: a randomized trial.
      ,
      • Mihmanli I.
      • Besirli K.
      • Kurugoglu S.
      • Atakir K.
      • Haider S.
      • Ogut G.
      • et al.
      Cephalic vein and hemodialysis fistula: surgeon's observation versus color Doppler ultrasonographic findings.
      ,
      • Georgiadis G.S.
      • Charalampidis D.G.
      • Argyriou C.
      • Georgakarakos E.I.
      • Lazarides M.K.
      The necessity for routine pre-operative ultrasound mapping before arteriovenous fistula creation: a meta-analysis.

      4.2 Imaging methods for vascular access surveillance

      4.2.1 Duplex ultrasound

      DUS as a non-invasive tool is the first line imaging method in patients with suspected VA dysfunction.
      • Tordoir J.
      • Canaud B.
      • Haage P.
      • Konner K.
      • Basci A.
      • Fouque D.
      • et al.
      EBPG on vascular access.
      • Doelman C.
      • Duijm L.E.
      • Liem Y.S.
      • Froger C.L.
      • Tielbeek A.V.
      • Donkers-van Rossum A.B.
      • et al.
      Stenosis detection in failing hemodialysis access fistulas and grafts: comparison of color Doppler ultrasonography, contrast-enhanced magnetic resonance angiography, and digital subtraction angiography.
      • Tattersall J.
      • Martin-Malo A.
      • Pedrini L.
      • Basci A.
      • Canaud B.
      • Fouque D.
      • et al.
      EBPG guideline on dialysis strategies.
      However, the diagnostic quality of DUS depends strongly on the experience of the examiner
      • Bay W.H.
      • Henry M.L.
      • Lazarus J.M.
      • Lew N.L.
      • Ling J.
      • Lowrie E.G.
      Predicting hemodialysis access failure with color flow Doppler ultrasound.
      • Schwarz C.
      • Mitterbauer C.
      • Boczula M.
      • Maca T.
      • Funovics M.
      • Heinze G.
      • et al.
      Flow monitoring: performance characteristics of ultrasound dilution versus color Doppler ultrasound compared with fistulography.
      • Wiese P.
      • Nonnast-Daniel B.
      Colour Doppler ultrasound in dialysis access.
      and provides no angiographic map for the guidance of further therapy.
      • Dumars M.C.
      • Thompson W.E.
      • Bluth E.I.
      • Lindberg J.S.
      • Yoselevitz M.
      • Merritt C.R.
      Management of suspected hemodialysis graft dysfunction: usefulness of diagnostic US.
      DUS locates and quantifies stenoses, allows flow measurements and detects thrombotic occlusions
      • Gadallah M.F.
      • Paulson W.D.
      • Vickers B.
      • Work J.
      Accuracy of Doppler ultrasound in diagnosing anatomic stenosis of hemodialysis arteriovenous access as compared with fistulography.
      • Older R.A.
      • Gizienski T.A.
      • Wilkowski M.J.
      • Angle J.F.
      • Cote D.A.
      Hemodialysis access stenosis: early detection with color Doppler US.
      • Shackleton C.R.
      • Taylor D.C.
      • Buckley A.R.
      • Rowley V.A.
      • Cooperberg P.L.
      • Fry P.D.
      Predicting failure in polytetrafluoroethylene vascular access grafts for hemodialysis: a pilot study.
      • Tordoir J.H.
      • de Bruin H.G.
      • Hoeneveld H.
      • Eikelboom B.C.
      • Kitslaar P.J.
      Duplex ultrasound scanning in the assessment of arteriovenous fistulas created for hemodialysis access: comparison with digital subtraction angiography.
      • Tordoir J.H.
      • Hoeneveld H.
      • Eikelboom B.C.
      • Kitslaar P.J.
      The correlation between clinical and duplex ultrasound parameters and the development of complications in arterio-venous fistulae for haemodialysis.
      but evaluation of the central veins may be limited.
      • Tattersall J.
      • Martin-Malo A.
      • Pedrini L.
      • Basci A.
      • Canaud B.
      • Fouque D.
      • et al.
      EBPG guideline on dialysis strategies.
      DUS is a cost-effective technique for the evaluation of VA maturation, surveillance and complications.
      • Lumsden A.B.
      • MacDonald M.J.
      • Kikeri D.
      • Cotsonis G.A.
      • Harker L.A.
      • Martin L.G.
      Cost efficacy of duplex surveillance and prophylactic angioplasty of arteriovenous ePTFE grafts.
      • Robbin M.L.
      • Chamberlain N.E.
      • Lockhart M.E.
      • Gallichio M.H.
      • Young C.J.
      • Deierhoi M.H.
      • et al.
      Hemodialysis arteriovenous fistula maturity: US evaluation.
      • Thalhammer C.
      • Aschwanden M.
      • Staub D.
      • Dickenmann M.
      • Jaeger K.A.
      Duplex sonography of hemodialysis access.
      If CVOD cannot be reliably excluded by DUS, additional imaging methods (e.g. DSA) will be necessary. Surveillance by DUS is reported to prolong AVG patency.
      • Malik J.
      • Slavikova M.
      • Svobodova J.
      • Tuka V.
      Regular ultrasonographic screening significantly prolongs patency of PTFE grafts.
      Only a few studies are available on DUS as a tool for ultrasound guided percutaneous transluminal angioplasty (PTA) of failing or non-maturing VA, which may be particularly indicated in patients with iodine contrast allergy or with residual kidney function.
      • Ascher E.
      • Hingorani A.
      • Marks N.
      Duplex-guided balloon angioplasty of failing or nonmaturing arterio-venous fistulae for hemodialysis: a new office-based procedure.
      • Gorin D.R.
      • Perrino L.
      • Potter D.M.
      • Ali T.Z.
      Ultrasound-guided angioplasty of autogenous arteriovenous fistulas in the office setting.
      Tabled 1
      Recommendation 9ClassLevelRefs
      Duplex ultrasound is recommended as the first line imaging modality in suspected vascular access dysfunction.IB
      • Doelman C.
      • Duijm L.E.
      • Liem Y.S.
      • Froger C.L.
      • Tielbeek A.V.
      • Donkers-van Rossum A.B.
      • et al.
      Stenosis detection in failing hemodialysis access fistulas and grafts: comparison of color Doppler ultrasonography, contrast-enhanced magnetic resonance angiography, and digital subtraction angiography.
      ,
      • Schwarz C.
      • Mitterbauer C.
      • Boczula M.
      • Maca T.
      • Funovics M.
      • Heinze G.
      • et al.
      Flow monitoring: performance characteristics of ultrasound dilution versus color Doppler ultrasound compared with fistulography.

      4.2.2 Computed tomography angiography

      Multislice computed tomography requires the use of iodinated contrast and radiation and should therefore only be used if no equivalent technique is available. However, compared with DSA computed tomography angiography (CTA) is a less invasive technique that provides important information for further treatment (surgery or PTA) and is less expensive than purely diagnostic DSA.
      • Ye C.
      • Mao Z.
      • Rong S.
      • Zhang Y.
      • Mei C.
      • Li H.
      • et al.
      Multislice computed tomographic angiography in evaluating dysfunction of the vascular access in hemodialysis patients.
      CTA is a reproducible and reliable technique for the detection of ≥50% stenosis or occlusion in dysfunctional AVFs
      • Heye S.
      • Maleux G.
      • Claes K.
      • Kuypers D.
      • Oyen R.
      Stenosis detection in native hemodialysis fistulas with MDCT angiography.
      and demonstrates excellent correlation in stenosis detection compared with DSA.
      • Wasinrat J.
      • Siriapisith T.
      • Thamtorawat S.
      • Tongdee T.
      64-slice MDCT angiography of upper extremity in assessment of native hemodialysis access.
      CTA allows the evaluation of the vascular tree in failing VA before treatment,
      • Wasinrat J.
      • Siriapisith T.
      • Thamtorawat S.
      • Tongdee T.
      64-slice MDCT angiography of upper extremity in assessment of native hemodialysis access.
      especially if supplemented by 3D image reconstructions.
      • Dimopoulou A.
      • Raland H.
      • Wikstrom B.
      • Magnusson A.
      MDCT angiography with 3D image reconstructions in the evaluation of failing arteriovenous fistulas and grafts in hemodialysis patients.
      Tabled 1
      Recommendation 10ClassLevelRefs.
      Computed tomographic angiography may be considered in patients with inconclusive ultrasonographic or angiographic results concerning the degree of central venous stenosis.IIbC
      • Wasinrat J.
      • Siriapisith T.
      • Thamtorawat S.
      • Tongdee T.
      64-slice MDCT angiography of upper extremity in assessment of native hemodialysis access.
      ,
      • Dimopoulou A.
      • Raland H.
      • Wikstrom B.
      • Magnusson A.
      MDCT angiography with 3D image reconstructions in the evaluation of failing arteriovenous fistulas and grafts in hemodialysis patients.
      ,
      • Rooijens P.P.
      • Serafino G.P.
      • Vroegindeweij D.
      • Dammers R.
      • Yo T.I.
      • De Smet A.A.
      • et al.
      Multi-slice computed tomographic angiography for stenosis detection in forearm hemodialysis arteriovenous fistulas.
      ,
      • Karadeli E.
      • Tarhan N.C.
      • Ulu E.M.
      • Tutar N.U.
      • Basaran O.
      • Coskun M.
      • et al.
      Evaluation of failing hemodialysis fistulas with multidetector CT angiography: comparison of different 3D planes.

      4.2.3 Magnetic resonance angiography (MRA)

      Gadolinium may cause nephrogenic systemic fibrosis (NSF) in patients with advanced impairment of renal function under HD. Therefore CE-MRA should be used only after carefully weighing the risks and benefits of alternative imaging studies.
      • Fraum T.J.
      • Ludwig D.R.
      • Bashir M.R.
      • Fowler K.J.
      Gadolinium-based contrast agents: A comprehensive risk assessment.
      Even in the era before NSF had been recognised, CE-MRA had not replaced DUS or DSA for pre-operative evaluation, but was believed to be appropriate in selected cases.
      • Laissy J.P.
      • Fernandez P.
      • Karila-Cohen P.
      • Delmas V.
      • Dupuy E.
      • Chillon S.
      • et al.
      Upper limb vein anatomy before hemodialysis fistula creation: cross-sectional anatomy using MR venography.
      • Paksoy Y.
      • Gormus N.
      • Tercan M.A.
      Three-dimensional contrast-enhanced magnetic resonance angiography (3-D CE-MRA) in the evaluation of hemodialysis access complications, and the condition of central veins in patients who are candidates for hemodialysis access.
      It allows non-invasive examination of the arterial and venous system.
      • Froger C.L.
      • Duijm L.E.
      • Liem Y.S.
      • Tielbeek A.V.
      • Donkers-van Rossum A.B.
      • Douwes-Draaijer P.
      • et al.
      Stenosis detection with MR angiography and digital subtraction angiography in dysfunctional hemodialysis access fistulas and grafts.
      • Han K.M.
      • Duijm L.E.
      • Thelissen G.R.
      • Cuypers P.W.
      • Douwes-Draaijer P.
      • Tielbeek A.V.
      • et al.
      Failing hemodialysis access grafts: evaluation of complete vascular tree with 3D contrast-enhanced MR angiography with high spatial resolution: initial results in 10 patients.
      Due to the rare use of MR guided VA interventions, CE-MRA is currently used as a purely non-invasive diagnostic tool and potential treatment must be performed by additional percutaneous intervention or surgery.
      • Bakker C.J.
      • Peeters J.M.
      • Bartels L.W.
      • Elgersma O.E.
      • Zijlstra J.J.
      • Blankestijn P.J.
      • et al.
      Magnetic resonance techniques in hemodialysis access management.
      In comparison with DSA used to evaluate complex AVFs, fewer complications and side effects were observed by the use of CE-MRA.
      • Menegazzo D.
      • Laissy J.P.
      • Durrbach A.
      • Debray M.P.
      • Messin B.
      • Delmas V.
      • et al.
      Hemodialysis access fistula creation: preoperative assessment with MR venography and comparison with conventional venography.
      Tabled 1
      Recommendation 11ClassLevelRef.
      Contrast enhanced magnetic resonance angiography is not recommended in patients with end stage renal disease, because of the potential risk of gadolinium associated nephrogenic systemic fibrosis.IIIC
      • Grobner T.
      Gadolinium–a specific trigger for the development of nephrogenic fibrosing dermopathy and nephrogenic systemic fibrosis?.

      4.2.4 Digital subtraction angiography

      In patients with VA dysfunction pure diagnostic DSA without subsequent intervention is not advised.
      • Tattersall J.
      • Martin-Malo A.
      • Pedrini L.
      • Basci A.
      • Canaud B.
      • Fouque D.
      • et al.
      EBPG guideline on dialysis strategies.
      In selected cases, DSA may be used in pre-operative vein mapping, e.g. when central stenosis or occlusion is suspected or for the surveillan