Department of Surgery, Umraniye Research and Training Hospital, Turkey

Kidney Disease Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines for Vascular Access have defined the access-related care for patients with end-stage renal disease [1]. However, the standard of care across the world has fallen short of the KDOQI targets. One potential explanation for these shortcomings is the lack of compelling evidence in the literature to support the recommendations. Arteriovenous Fistula (AVF) is the optimal vascular access for hemodialysis as it is associated with prolonged survival, fewer infections, lower hospitalization rates, and reduced costs [2]. Access complications are common and require early recognition and treatment. Postoperative access surveillance is important to ensure timely diagnosis and treatment of access-related complications. There is a continued need for high-quality data to assist in determining the best access for each patient. The AVF First breakthrough initiative has made dramatic progress, effectively promoting the increase in the AVF prevalence since the program's inception [3]. Optimal surgical practice makes it obvious that when planning permanent access placement, one should always consider the most distal site possible to permit the maximum number of future possibilities for access. In general, peripheral-to-central sequence of fistulae construction should be envisioned in ideal cases. Options for fistula placement should be considered first, followed by prosthetic grafts if fistula placement is not possible or in case of previous failures. Surgeon should plan and do the best access possible, while the nephrologist should monitor and fight for its patency and thereby improve not only the quality of life but also to combat mortality. Maintaining long-term functioning access can be difficult and frustrating for physicians and patients; starting distally and moving proximally provides for the possibility of preserving as many potential sites as possible for future access creation. It is a tragedy for patients and caretakers alike to exhaust anatomic sites prematurely by initially bypassing more distal sites.

References

1. Biuckians A, Scott EC, Meier GH, Panneton JM, Glickman MH (2008) The natural history of autologous fistulas as first-time dialysis access in the KDOQI era. J Vasc Surg 47: 415-421.
   


2. Drew DA, Lok CE (2014) Strategies for planning the optimal dialysis access for an individual patient. Curr Opin Nephrol Hypertens 23: 314-320.
   


3. Vassalotti JA, Jennings WC, Beathard GA, Neumann M, Caponi S, et al. (2012) Fistula first breakthrough initiative: targeting catheter last in fistula first. Semin Dial 25: 303-310.