Optimizing Dialysis Vascular Access: Moving beyond Fistula First.

Area of Science:

• Nephrology
• Vascular Surgery
• Dialysis Access Management

Background:

• Historically, arteriovenous fistulas (AVFs) were preferred over arteriovenous grafts (AVGs) due to better long-term outcomes and lower costs.
• Recent evidence challenges the universal
• Fistula First
• strategy, highlighting significant AVF nonmaturation rates (30-40%) and complications.

Purpose of the Study:

• To evaluate the effectiveness of the
• Fistula First
• strategy versus a more selective approach to vascular access placement in hemodialysis patients.
• To compare procedural frequency and cost of access management between AVFs and AVGs.

Main Methods:

• Review of existing research and guidelines on vascular access placement.
• Analysis of outcomes including AVF nonmaturation rates, intervention requirements, and cost-effectiveness.
• Comparison of
• Fistula First
• strategy with a selective strategy favoring AVGs in high-risk patients.

Main Results:

• AVF nonmaturation is substantial, particularly in women, older adults, and those with peripheral vascular disease.
• Assisted maturation of AVFs leads to poorer outcomes and increased interventions.
• A selective strategy, prioritizing AVGs for high-risk patients, is associated with fewer procedures and lower annual access management costs.

Conclusions:

• The
• Fistula First
• strategy may not be universally optimal.
• A patient-centered, selective approach to vascular access (AVF vs. AVG) can improve outcomes, reduce procedural burden, and lower costs.
• The 2019 Kidney Disease Outcomes Quality Initiative guidelines advocate for personalized vascular access selection.