Right access for the right elderly patient: A proportional, frailty-informed framework for vascular access selection

The "Fistula First" paradigm has long guided vascular access selection in hemodialysis, but its applicability in the growing elderly population is increasingly questioned. Aging, frailty, and comorbidity burden significantly influence vascular access outcomes, challenging a uniform approach.

We performed a narrative, pathophysiology- and evidence-based analysis of vascular access strategies in elderly patients on hemodialysis. We propose a patient-centered, proportionate decision-making framework integrating prognostic stratification, frailty assessment, cardiovascular risk, vascular anatomy, and patient goals of care. A novel multidimensional tool, the Proportional Access Score (PAS), was developed to operationalize this approach.

In elderly and frail patients, the clinical benefit of AVF is attenuated by higher primary failure rates, delayed maturation, and increased procedural burden, often without clear survival advantage. Conversely, CVC use, although associated with infectious and thrombotic risks, may represent a proportionate strategy in selected patients with limited life expectancy or high clinical vulnerability. Evidence suggests that vascular access type reflects patient selection rather than acting as an independent determinant of outcomes. Frailty emerges as a key modifier of risk-benefit balance, influencing access performance, complications, and quality of life. The proposed PAS enables stratification along a continuum of clinical vulnerability, supporting AVF-first strategies in robust patients, hybrid approaches in intermediate profiles, and catheter-centered strategies in highly frail individuals.

Vascular access selection in elderly patients should move beyond a "one size fits all" model toward a proportionate, patient-centered strategy. Integration of frailty, prognosis, and patient preferences allows alignment of access choice with realistic clinical benefit. The Proportional Vascular Access Framework and PAS provide pragmatic tools to support individualized decision-making and may contribute to redefining standards of care in the elderly hemodialysis population.