The endless history of vascular access: a surgeon's perspective

Gaining access to blood circulation has been a major breakthrough of modern medical care and, despite the evolution of dialysis technology, vascular access (VA) remains the main impediment in providing quantity as well as quality of life to the end-stage renal disease (ESRD) patient. The external Scribner shunt and the internal Brescia/Cimino arteriovenous fistula (AVF) opened the way for further advancements such as graft angioaccess and other sophisticated devices. Forty years later, the radio-cephalic fistula remains the VA with the longest patency and the lowest complications. Although various technical solutions can be adopted for constructing access to the patient's vessels, the nephrologist must bear in mind that every VA in the upper limb, lower limb or body wall needs a run-in and a run-off: currently, thrombosis of the central vessels due to the excessive widespread use of central venous catheters (CVCs) emerge as a substantial cause of hemodialysis (HD) morbidity and mortality. Moreover, as there is a risk of central vein stenosis, even 2 weeks after catheter placement, and an impaired venous outflow precludes the creation of any VA and sometimes the placement of a kidney transplant in the iliac fossa for many years, we agree with McGill et al, who in 2005 said that ''expansion of catheter access may contribute to the reduced survival of hemodialysis patients in the United States''.