Some of the Dilemmas About Creating Arteriovenous Fistulas for Hemodialysis

The native arteriovenous fistula for haemodialysis has been described as the Achilles heel but also the Cinderella of haemodialysis. Arteriovenous fistula has been the vascular access of choice for haemodialysis, because of lower cost, morbidity and mortality. The significance of a functioning vascular access is that it takes on a major role in determining a positive outcome. Yet, they are a cause of great stress, both for patients and healthcare professionals. About 80% of patients begin dialysis with central venous catheters, 20-70% of fistulas do not reach maturity, and a fifth, of all fistulas, thrombosed before use. A quarter die from poor vascular access. Insufficient number of vascular surgeons and inadequate training to create vascular access often lead to "congestion" of the bed stock in nephrology. Surgeons and radiologists perform all procedures related to vascular approaches, but the dominant role of nephrologists is in the organization of planning and realization of creating a vascular access. Initiation of dialysis in the elderly and diabetics, as a risk population of patients for arteriovenous fistula, is associated with many problems, among which the creation, functioning and maturation of the vascular access dominate. Hyperdynamic conditions, due to arteriovenous communication in patients with arteriovenous fistula, are cited as a possible mechanism for increasing morbidity. However, there is still no agreement within the nephrology community regarding the height of the hemodynamic load and the indication for closing the vascular access. There are many dilemmas associated with creating, care and using an arteriovenous fistulas, and that could be the reason and justification to form a team for vascular access, which would, in addition to nephrologists, include vascular surgeons, interventional radiologists and nurses.