Long-Term Results of Biological Grafts for Haemodialysis Vascular Access

The quest for suitable conduits for dialysis access has continued since the first patients were dialysed. Whilst synthetic grafts made from expanded polytetrafluoroethylene (ePTFE) have been the main definitive option after autologous arteriovenous fistulas they have a number of drawbacks, which has led to the use and development of biological grafts such as autografts, homografts or xenografts. Technology continues to improve and currently biosynthetic options are available which may combine the benefits of a readily available product without the drawbacks of PTFE. The history and evidence of biological options for haemodialysis access are discussed.

Vascular access for hemodialysis: current perspectives

A well-functioning vascular access (VA) is a mainstay to perform an efficient hemodialysis (HD) procedure. There are three main types of access: native arteriovenous fistula (AVF), arteriovenous graft, and central venous catheter (CVC). AVF, described by Brescia and Cimino, remains the first choice for chronic HD. It is the best access for longevity and has the lowest association with morbidity and mortality, and for this reason AVF use is strongly recommended by guidelines from different countries. Once autogenous options have been exhausted, prosthetic fistulae become the second option of maintenance HD access alternatives. CVCs have become an important adjunct in maintaining patients on HD. The preferable locations for insertion are the internal jugular and femoral veins. The subclavian vein is considered the third choice because of the high risk of thrombosis. Complications associated with CVC insertion range from 5% to 19%. Since an increasing number of patients have implanted pacemakers and defibrillators, usually inserted via the subclavian vein and superior vena cava into the right heart, a careful assessment of risk and benefits should be taken. Infection is responsible for the removal of about 30%-60% of HD CVCs, and hospitalization rates are higher among patients with CVCs than among AVF ones. Proper VA maintenance requires integration of different professionals to create a VA team. This team should include a nephrologist, radiologist, vascular surgeon, infectious disease consultant, and members of the dialysis staff. They should provide their experience in order to give the best options to uremic patients and the best care for their VA.