Vascular access 2007

Over the past decades, vascular access management has undergone profound changes resulting in marked improvements in patient care. AV fistulae remain the access of choice and continue to represent the majority of accesses in most countries. Access monitoring is more widely available and new percutaneous therapies have revolutionized the therapeutic approach to access failure. Outpatient access centers providing both percutaneous and surgical therapies have decreased the need for vascular access related hospitalization. These advances have been supported by the development and promulgation of standardized evidence-based guidelines. These guidelines supported by national and international outcome data have helped rationalize vascular access care. Despite these advances many challenges remain. Catheter use has increased on a worldwide basis, with resultant increases in catheter related infections and complications including sepsis, endocarditis and paravertebral abscess. The availability and use of standardized chronic kidney disease care including early access placement in preparation for dialysis initiation remains underutilized in most settings. Payment system and structural barriers often provide disincentives for the efficient outpatient application of available technologies and there are a few available large prospective trials to help guide therapies. As we look to the future, it is anticipated that a wide range of new technologies will continue to improve vascular access management. Enhancing our delivery systems, combined with he thoughtful application of these technologies including new biologics, materials, interventional techniques and cellular technologies offer the promise of continued improvements in patients vascular access care over the coming decade.