A primer on the av fistula—Achilles' heel, but also Cinderella of haemodialysis

The first surgical creation of an arteriovenous fistula for the purpose of haemodialysis was performed in 1965 by Brescia, Cimino and co-workers at New York—a real break-through in the field of vascular access [1]. More than 30 years later, two basic aspects have changed: First, more and more elderly and diabetic patients are accepted for long-term dialysis treatment and a rising proportion of patients with a history of dialysis therapy over more than 20 years is observed presenting special vascular, mainly arterial, problems. Second, graft materials, permanent central venous catheters, diagnostic and interventional radiological techniques and ultrasonographic investigations have been introduced. It is a poor strategy to start dialysis treatment when residual renal function is lower than the accepted optimum for patients on dialysis treatment. At a serum creatinine level of more than 6–8 mg/dl in non-diabetic patients and of more than 4–6 mg/dl in diabetic patients dialysis therapy should be started.