[A good vascular access allows an effective treatment]

Vascular access (VA) for dialysis is defined as the 'Achilles heel', but also the 'Cinderella' of dialysis, indicating the poor consideration of the problem whether in the surgical environment, or in incomprehensible way in that nephrologic. It can only aspire to the definition 'Fundamental detail'. However, presupposed effective dialysis is a blood flow rate of 300-350 mL/min. Good VA must be easy to prepare, long lasting, free from complications, and aesthetically acceptable and economical. The arteriovenous fistula (AVF) of Cimino and Brescia, from 1966, represents the gold standard and the model of comparison for other systems, more technologically advanced. It must be programmed with an adapted margin (1-2 months) to allow maturation and access certainty for the first puncture, and never carried out sooner than 14 days from the operation. It is known from hemodynamic studies that the good functional flow of the new fistula can already regain 400-500 ml/min in the first week, with cardiological implications like the increase in cardiac throw, in ejection fraction and in the cardiac index. Health workers, patients and dialysis staff must follow a continuous educational program to protect the VA and avoid 'routine and absent-minded management', a basis for its premature failure. The nephrologist must take the responsibility upon himself not to carry out 'medical malpractice'. In the Dialysis Center of Mantova, the VA 'road map' previews all patients (young and old, affections from mono or pluropathology), first the fistula to the wrist, then the cephalic proximal. It follows the basilic vein transposition, the vascular graft to the arm or to the groin, as an alternative to peritoneal dialysis. The permanent central venous catheter (CVCp) is the last choice in patients with reduced life expectancy, heart failure, neoplastic patients with vascular patrimony destroyed by chemotherapy and ischemic lesions produced by the fistula. There were 180 afferent prevailing patients at the Mantova Dialysis Center . The natural fistula rate was 91%, grafts 7% and CVCps 2%. Between 2000 and 31 March 2004 we prepared 367 VAs. Average patient age was 65 yrs, range 20-90 yrs; 59% male and 41% female. Eighty-eight percent of operations were performed by the nephrologist (distal fistula, rescue and cephalic proximal) and 12% by the vascular surgeon (basilic vein transposition, graft in PTFE stretch to the arm and to the groin and permanent catheter in the jugular vein). The fistula with native veins was the better solution, the graft must be prepared after the exhaustion of natural possibilities, and the CVCp, for serious complications (inadequate flow and infections), must be the last alternative.