Optimizing dialysis vascular access: moving beyond Fistula First

For many years, the vascular access guidelines recommended placement of arteriovenous fistulas (AVFs) in preference to arteriovenous grafts (AVGs) because AVFs had superior long-term patency, required fewer interventions to maintain patency, and were associated with lower costs of vascular access management. However, subsequent research has questioned the “Fistula First strategy” (placing an AVF whenever the vascular anatomy is suitable). First, AVF non-maturation is substantial (30-40%), and even higher among women, older patients and those with peripheral vascular disease. Second, about half of AVFs require surgical or percutaneous interventions to assist maturation. Moreover, AVFs that require assisted maturation have shorter patency and require more frequent interventions, as compared to AVFs with unassisted maturation. Third, in an intent-to-treat analysis, when the Fistula First strategy is followed in patients initiating hemodialysis with a central vein catheter (CVC), the annual frequency of access procedures and the overall cost of access management is substantially greater for AVFs than AVGs. Fourth, in patients with advanced chronic kidney disease (CKD) undergoing pre-dialysis access AVF rather than AVG placement, initiation of dialysis with a CVC is much more common. An alternative strategy is a more selective one, in which patients at high risk of AVF non-maturation preferentially receive an AVG, even if the vascular anatomy is suitable for an AVF. As compared to the Fistula First strategy, the more selective vascular access strategy is associated with fewer access procedures and a lower annual cost of access management. In summary, a more nuanced, patient-centered approach to vascular access may improve access outcomes, decrease the burden of access procedures, and lower the overall costs of vascular access management. This realization has been distilled in the 2019 updated Kidney Disease Outcomes Quality Initiative (KDOQI) Vascular Access Guidelines, which exhort nephrologists and surgeons to “place the right access in the right patient at the right time for the right reason”.