Totally implantable subcutaneous devices for hemodialysis access

Subcutaneous hemodialysis access systems represent a uniquely different hemodialysis access option. The ideal role for these devices is to help patients to achieve a functioning AV fistula by providing temporary access while patients are waiting for the creation or maturation of an AV fistula. An ideal bridge device would allow for immediate use following placement, provide blood flow rates sufficient to ensure adequate dialysis, have a low complication rate, and have sufficient length of technical survival to allow AV fistula development and maturation without the need for device replacement. Clinical data reported to date supports the use of subcutaneous hemodialysis access systems as a bridge device instead of a hemodialysis catheter [11, 12, 17-20]. The increased emphasis on AV fistula placements in patient populations who are at higher risk of having fistulas that fail to mature increases the need for a bridge device which provides improved outcomes during longer maturation periods especially in patients in whom more than one fistula attempt is made or for patients who are receiving upper arm fistulas [21, 36]. Several studies have also documented the utility of subcutaneous hemodialysis access systems in catheter-dependent patients who have exhausted other access options [12-15, 19, 20]. The hope offered for improved outcomes in this patient population should be tempered by realistic expectations for device performance especially in patients with significant morbidities, poor vasculature, a history of poorly performing hemodialysis catheters, or multiple catheter-related infections. Totally subcutaneous hemodialysis access systems offer a unique option for ESRD patients. The development of these devices represent a key step towards improving dialysis delivery and hemodialysis vascular access-related outcomes. Following recommended procedures for implanting, accessing and maintaining these devices is key towards achieving optimal device performance.