Vascular access problems in dialysis patients: pathogenesis and strategies for management

Repetitive hemodialysis was made possible through the development of a chronic means of accessing the circulation. This was accomplished through the use of arteriovenous fistulae or grafts, using autologous veins or synthetic materials. Although the arteriovenous fistula remains the access of choice, synthetic arteriovenous grafts are used in most patients because of problems with late referral to a nephrologist and poor vasculature. This article describes the means of accessing the circulation for hemodialysis, the pathogenesis of access failure through progressive stenosis followed by thrombosis, methods of detecting access dysfunction before thrombosis, and therapeutic options. Although angiographic or surgical intervention remain the mainstays of management, medical treatments to decrease stenosis and delay thrombosis are currently under investigation.