Key points

• Planning for vascular access in renal failure needs to begin at least 6 months prior to the predicted onset of dialysis

• Surgery should be aimed at the most distal veins first to preserve the more proximal ones

• Autologous arteriovenous (AV) fistula are the most durable form of access

• Most access procedures can be performed under local anaesthesia as day case surgery

• A good access programme should have an individual to coordinate investigations and surgery

• Surveillance improves access graft function and longevity

Introduction

Vascular access is required in those patients where frequent repeated access to the circulation is required. The vast majority need this for haemodialysis to treat renal failure. Other examples are for plasmapharesis, injection of antibiotics (e.g. cystic fibrosis) or drugs (e.g. in chemotherapy for neoplasia).

The focus of this chapter will be on the provision and maintenance of vascular access for haemodialysis, but the principles of access placement and surveillance hold good for patients with alternative requirements.

Diagnosis of need for access placement

At first sight this appears straightforward. Those patients with end-stage chronic kidney disease will need dialysis and should have access placed. As AV fistula have the lowest morbidity and failure rate, once established, this is regarded as the ‘ideal’ form of access. Many fistula and all grafts will require surveillance and some may need interventions to keep them functioning adequately.