Introduction

(1)

Department of Vascular Surgery, Evangelisches Krankenhaus Königin Elisabeth Herzberge, Berlin, Germany

1.1 Introductory Principles

In order to provide satisfactory care for a vascular hemodialysis access, it is important to be familiar with some basic principles.

The hemodialysis patient’s survival depends on the vascular access.
Efficiency of dialysis, quality of life, and life expectancy also depend on the vascular access.
Each vascular access alters the former physiological state. Consequently, its creation triggers various physiological and pathophysiological reactions.
Thus the life span of every vascular access is limited. A new access frequently entails the loss of native vessels.
The maturation of a vascular access and its life span are based on biological reactions, the surgical procedure, and puncture techniques. Therefore they are not entirely predictable.
Vascular access puncture can only be as good as the prior surgical procedure permits.
Apart from functionality, the option for a large number of potential future vascular accesses is a crucial criterion when deciding which access to create.
There are almost always multiple options for creating a permanent hemodialysis access.
A vascular surgeon needs to know about hemodynamics just as an architect needs to know about structural analysis.
The selection of the type of access that is most suitable at a given stage requires profound knowledge. This knowledge is of the utmost importance before embarking on any vascular access surgery.
From a pathophysiological point of view, there are major differences between an arteriovenous (AV) vascular access and an arterial bypass. They cannot be compared to each other.
Responsible vascular access surgery can only be performed if the surgeon can deal intensively with a large number of patients over a long period of time.
Before a novel method is adopted, it should be examined with regard to its physiological suitability and theoretical advantages over existing methods.

The best vascular access is not necessarily that which primarily promises the longest life span. Preference should be given to that which allows for the longest complication-free hemodialysis therapy when taking into account possible future procedures.

Except for extremely rare constellations, which we have not observed so far, a permanent vascular access for hemodialysis is always feasible.

1.2 Vascular Access for Hemodialysis

For hemodialysis there has been a plethora of historic developments which have partly been abandoned (such as Scribner and Buselmaier shunts). A whole variety of graft materials has also been developed. An early major step in AV access surgery was the creation of an arteriovenous anastomosis by Cimino and Brescia.

Basically there are three different options for connecting patients to the hemodialysis machine:

Central venous catheters (temporary, permanent)

Two variants of arteriovenous access