Arteriovenous fistula surveillance: Everyone's responsibility

Abstract

The arteriovenous fistula, as opposed to arteriovenous grafts and central venous dialysis catheters, remains the dialysis access of choice for haemodialysis patients, due to its superior long term patency, low incidence of stenosis, thrombosis and infection. The basic tenant of vascular access monitoring and surveillance is that stenosis develops over a variable amount of time in a majority of arteriovenous fistula, and if detected and corrected, inadequate dialysis can be prevented, maturation can be facilitated and thrombosis and access loss can be avoided. Large randomised controlled trials are lacking to clearly identify the ideal surveillance strategies and benefits of surveillance, often only supported by observational studies and small single -centre randomised controlled trials. Fistula thrombosis is often used as an endpoint in trials looking at the beneficial effects of surveillance, although this occurs relatively infrequently in native arteriovenous fistula, and therefore other markers are required to define a dysfunctional fistula. Cost effective ways to improve outcomes in these types of vascular accesses involves formalised training of staff and other healthcare professionals to better identify dysfunctional fistulas by physical examination, with the addition of surveillance studies to support these findings and pre-emptive intervention when stenosis is found. The costs invested in establishing multidisciplinary programmes to facilitate the care of these patients will likely reduce long term resource utilisation in a growing population of dialysis patients worldwide. In this review, we examine the physiology of a dysfunctional fistula and evaluate available studies in the surveillance of arteriovenous fistulas. In addition, the importance of creating secondary arteriovenous fistula and how healthcare systems need to invest in improving the care of haemodialysis vascular access will be outlined.