Hemodialysis Access Planning, Selection, and Creation

60.1ESKD Life-Plan and access choice

Hemodialysis access planning begins with the patient’s anticipated dialysis trajectory, not with the surgeon’s preferred conduit. The 2019 KDOQI vascular access guideline reframed access selection around the ESKD Life-Plan: an individualized sequence of current and future access options that accounts for life expectancy, comorbidity, expected duration of hemodialysis, transplant likelihood, current dialysis status, and the consequences of exhausting future access sites. KDOQI clinical practice 2019 · KDOQI 2019 This approach deliberately moved away from rigid “fistula-first” targets toward patient-centered targets for arteriovenous fistula, arteriovenous graft, and catheter use, supported by GRADE Evidence-to-Decision methodology rather than purely prescriptive performance goals.

For the vascular surgeon, the Life-Plan is a practical operative document. It should state whether the patient is predialysis or already dialyzing, whether dialysis is expected to be short-term or long-term, whether the patient has realistic transplant or peritoneal dialysis options, which extremities and central venous pathways remain usable, and what access will be used if the first plan fails. The decision should also record the intended first access, the reason that access was chosen, the anticipated maturation interval or bridge requirement, and the next-best option if maturation fails or cannulation cannot be achieved. UK Kidney Association 2025 · KDOQI clinical practice 2019 · UKKA 2025

All patients approaching hemodialysis should be considered for structured access assessment, but the intensity and timing of assessment should be matched to the clinical problem. A young patient with long expected dialysis exposure and usable superficial veins may appropriately be planned toward durable autogenous access, whereas a frail patient with limited life expectancy, urgent dialysis dependence, poor target veins, or high likelihood of early access failure may be better served by a graft or catheter-bridged sequence rather than repeated unsuccessful fistula attempts. The KDOQI update explicitly leaves room for clinician judgment and local expertise, and the UK Kidney Association guideline similarly frames access decisions as graded recommendations rather than absolute rules. UK Kidney Association 2025 · UKKA 2025 · KDOQI 2019

The historical contrast between Europe and the United States illustrates why access planning cannot be reduced to patient anatomy alone. In DOPPS, prevalent AVF use was 80% in European facilities and 24% in US facilities; after adjustment for age, sex, body mass index, diabetes, and peripheral vascular disease, European facilities remained 21-fold more likely to use AVFs than US facilities. Such differences reflect referral timing, surgical practice, dialysis-unit culture, and system organization as much as patient-level biology. Vascular access use 2002

Access failure is often a process failure before it becomes a technical failure. Practice-level analyses identified five recurrent barriers to higher AVF prevalence: delayed dialysis-access referral, the type of fistula attempted, patient demographics, clinician preference, and vessel anatomy. Increasing arteriovenous fistulas 2002 A mature program therefore needs coordinated nephrology, vascular surgery, interventional, anesthesia, and dialysis-nursing participation, with agreed thresholds for referral, mapping, access creation, cannulation readiness, and escalation when the access is not progressing. Association Anaesthetists guidelines 2025

Device selection also belongs inside the access plan. Safe vascular access guidance from the Association of Anaesthetists emphasizes process responsiveness, device selection, ultrasound-guided insertion, tip confirmation, maintenance, dressing practice, complication response, and operator training. For the hemodialysis patient, this means that any catheter decision should be treated as part of the overall access sequence, not as an isolated procedure; the access team should know whether a catheter is a short bridge to an AVF, a bridge to AVG creation, or the least burdensome long-term option in a patient whose Life-Plan does not support repeated surgical attempts. Association Anaesthetists guidelines 2025 · KDOQI clinical practice 2019

The operative note and clinic letter should be explicit enough to guide the next clinician. At minimum, documentation should include the Life-Plan rationale, selected access type and location, relevant patient factors such as age, cardiovascular disease, peripheral vascular disease, diabetes, and dialysis status, the available vessel-map findings, the expected route to cannulation, the contingency access, and the follow-up trigger that will prompt reassessment. This documentation is particularly important when the plan departs from a default distal autogenous strategy, because KDOQI’s contemporary framework supports individualized access choice but requires that the reasoning be visible. KDOQI clinical practice 2019 · KDOQI 2019

60.2Preoperative vessel and patient assessment

Preoperative assessment should answer two linked questions: whether the patient is likely to benefit from an autogenous access attempt, and which artery-vein pairing offers the best balance between maturation probability, cannulation usability, and preservation of future sites. Contemporary data support liberal use of ultrasound mapping. In a Vascular Quality Initiative cohort of 46,010 patients undergoing AVF or AVG placement between 2011 and 2019, 85.6% had preoperative vein mapping; 76.1% underwent AVF creation and 23.9% AVG creation, allowing mapping practice to be related to configuration, one-year secondary patency, and reintervention. Association preoperative vein 2022

An updated meta-analysis of 18 studies including 3655 participants found that routine preoperative ultrasound mapping reduced primary AVF failure, with a pooled risk ratio of 0.56 and a stronger RCT-only estimate of 0.37. Pre-operative ultrasound mapping 2023 · Preop US Mapping 2024 Although the overall certainty was low, the randomized evidence supports routine mapping in many clinical environments, especially where surgical expertise is variable, where physical examination is equivocal, or where the cost of a failed first access would be high.

The bedside examination remains essential, but it should not be the only selection tool when the access decision is consequential. Clinical examination identifies gross arterial insufficiency, prior incisions, visible superficial veins, edema, and limb dominance, while ultrasound defines target vein continuity, diameter, depth, compressibility, and arterial inflow in a reproducible way. The HFM Study showed that once postoperative ultrasound measures of AVF blood flow, vein diameter, and vein depth were known, case-mix factors added little additional prognostic information for clinical maturation, reinforcing the central role of anatomic and hemodynamic measurement in access planning. Pre-operative ultrasound mapping 2023 · Prediction Arteriovenous Fistula 2018 · Preop US Mapping 2024

Risk stratification should be used to temper optimism, not to deny access reflexively. The REDUCE FTM I rule, derived in 422 first-fistula patients and externally validated in 445 patients across five North American centers, identified age 65 or older, peripheral vascular disease, coronary artery disease, and non-white race as predictors of failure to mature. Ftm prediction rule 2006 The odds ratios were 2.23 for age at least 65, 2.97 for peripheral vascular disease, 2.83 for coronary artery disease, and 0.43 for white race, indicating that patient-level risk can be substantial even before the surgeon chooses the access configuration.

Risk models are most useful when they change the access sequence. A high-risk patient with poor distal veins may still be offered an AVF if the Life-Plan values long-term autogenous access and there is time for maturation, but the same risk profile in a catheter-dependent patient may justify an earlier graft strategy, closer post-creation ultrasound, or a clearer contingency plan. The HFM cohort of 602 participants, including 380 dialysis and 222 predialysis patients, provides a practical benchmark because unassisted maturation and longer-term functional patency were tracked while remedial interventions were discouraged within the first 6 weeks after creation. KDOQI clinical practice 2019 · Arteriovenous Fistula Maturation 2021

Anesthesia planning is part of preoperative access assessment, not a late operating-room detail. In a secondary analysis of the HFM cohort, unassisted AVF maturation was higher with regional or local anesthesia than with general anesthesia: 164 of 309 patients, or 53.1%, versus 91 of 226 patients, or 40.3%, with the association persisting after adjustment for patient factors and fistula type. Association between anaesthesia 2022 This does not make general anesthesia wrong, but it supports early anesthesia discussion when the patient can safely undergo regional or local techniques and when improving the probability of unassisted maturation is clinically important.

Laboratory and biologic predictors remain investigational for routine surgical selection. In the HFM Study, mineral metabolism markers including FGF-23, parathyroid hormone, calcium, phosphate, and vitamin D metabolites were examined in relation to vein histology and AVF maturation within 9 months of surgery or 4 weeks after dialysis initiation. Mineral Metabolism Disturbances 2019 Bioinformatic analyses have also identified inflammatory and immune-response pathways during vein remodeling, with diabetic patients showing blunted immune-effector signatures compared with non-diabetic patients, but these findings are not yet a substitute for clinical assessment, ultrasound mapping, and individualized Life-Plan selection. Bioinformatics identifies predictors 2024

For patients being considered for percutaneous endovascular AVF creation, mapping must specifically test device eligibility rather than merely describing superficial veins. In a 100-patient ultrasound-mapping screen for first access, 63% of patients and 50% of limbs met minimum Ellipsys eligibility, defined as a patent proximal radial artery and adjacent perforating elbow vein each at least 2 mm in diameter and within 1.5 mm of each other. Feasibility arteriovenous fistula 2020 Roughly half of predialysis patients therefore lacked suitable anatomy for this approach, making anatomic screening a decisive step rather than an administrative formality.

The mapping report should be formatted for surgical decision-making. It should identify usable arteries and veins by limb and level, document whether the target supports distal forearm, upper-arm, transposed, graft, or percutaneous options, and state the reason that an otherwise appealing option is rejected. When percutaneous AVF is being considered, the report should explicitly record proximal radial artery patency, perforator vein diameter, and artery-vein distance; when surgical AVF or AVG is being considered, it should clarify whether the selected conduit is intended as a first access or as part of a catheter-bridged sequence. KDOQI clinical practice 2019 · Pre-operative ultrasound mapping 2023 · Preop US Mapping 2024 · Feasibility arteriovenous fistula 2020

Emerging tools may expand the access team’s ability to assess maturation outside a conventional vascular laboratory. On a benchtop AVF model, the FDA-cleared EchoSure 3D Doppler device used by novice operators achieved a volume-flow error of 8%, comparable to expert-operated duplex ultrasound, in a context where traditional duplex surveillance compliance in dialysis units has been poor. Automated D ultrasound 2023 Such systems should be viewed as adjuncts to a structured program: they may help standardize flow measurement and triage, but the surgeon must still integrate flow, vein diameter, vein depth, cannulation feasibility, and the patient’s Life-Plan. Prediction Arteriovenous Fistula 2018

60.3AVF, AVG, and catheter sequencing

The default access sequence should preserve future options while delivering a usable access within the patient’s clinical timeline. AVFs remain attractive because a 2025 meta-analysis of 63 studies and 357,333 patients found AVF associated with higher one-year primary patency, primary-assisted patency, and secondary patency than AVG; the reported odds ratios were 1.61 for primary patency and 1.69 for primary-assisted patency, with fistula site and transposition modifying effect size. AVF 2025 · AVF vs graft outcomes meta-analysis 2025 This evidence supports AVF when the patient has suitable anatomy and sufficient time for maturation, but it does not justify repeated low-probability fistula attempts in every patient. KDOQI clinical practice 2019

The distal radiocephalic AVF remains an important first-access option when anatomy and timing support it. A meta-analysis of 36 cohort studies reported radiocephalic forearm AVF primary patency rates of 84.18% at 30 days, 68.43% at one year, 59.86% at two years, and 55.10% at 3 years. These pooled benchmarks are useful in counseling: the distal forearm access preserves proximal sites and can provide durable access, but the patient should understand that primary patency declines over time and that maturation failure remains a real possibility. AVF 2025 · Forearm AVF Patency 2025

Upper-arm autogenous access should not be reduced to a reflexive brachiocephalic-first rule. In a prospective single-center database of 678 upper-arm accesses, primary failure was lowest for brachiobasilic transpositions and grafts, at 15% and 18%, and highest for brachiocephalic fistulas, at 38%. Outcomes brachiocephalic fistulas 2009 Brachiocephalic fistulas carried a 2.76-fold higher hazard of primary failure than brachiobasilic fistulas, demonstrating that access type within the upper arm materially influences early failure independent of patient-level covariates.

The brachiobasilic transposition is therefore a deliberate strategy rather than merely a salvage operation. When cephalic anatomy is poor or the probability of brachiocephalic failure is high, a brachiobasilic option may better match the patient’s Life-Plan, provided the patient can tolerate the operation and the access team can manage the expected maturation and cannulation pathway. The Lok upper-arm series included 322 brachiocephalic fistulas, 67 brachiobasilic transpositions, and 289 grafts, emphasizing that the surgeon should choose among upper-arm options using anatomy, early-failure risk, and dialysis urgency rather than a single hierarchy. KDOQI clinical practice 2019 · Outcomes brachiocephalic fistulas 2009

AVGs are not failed AVFs; they are appropriate access choices when they best fit the patient’s anatomy, urgency, and expected dialysis course. In a 980-patient single-center AVG cohort from 2014 to 2022, secondary patency improved significantly from the first to the third practice period, with improvement attributed to graft-type changes, anastomosis-site shifts, and adoption of endovascular interventions. Impact evolving strategies 2025 This evolution supports treating AVG creation as a technically and strategically active field rather than as a static second-best option.

When a new graft is chosen, pharmacologic adjuncts may be relevant to the overall plan. In a randomized, double-blind, placebo-controlled trial of 649 new AVG patients at 13 US centers, extended-release dipyridamole 200 mg plus aspirin 25 mg twice daily improved primary unassisted graft patency compared with placebo; one-year unassisted patency was 23% in the treatment arm and 13% in the placebo arm, with absolute risk reduction sustained at 4.5 years. Effect Dipyridamole plus 2009 This evidence should be interpreted in the context of bleeding risk, medication tolerance, and local practice, but it is directly relevant when planning a graft-dependent access pathway.

Catheters remain part of hemodialysis care, but catheter-first dialysis should be recognized as a marker of access-system failure when avoidable. In a Romanian national registry cohort of 6863 incident hemodialysis patients from 2020 to 2022, only 20% started dialysis with an AVF, while 55% started with a temporary CVC and 25% with a tunneled CVC. Patterns outcomes vascular 2025 AVF survival was longer, with a median of 39.1 months, and CVC initiation carried more than double the mortality hazard, underscoring the importance of timely planning and catheter minimization when the patient’s Life-Plan allows.

The surgeon should also recognize inequity as a technical planning issue. In a USRDS-Medicare cohort of 9458 elderly catheter-initiation patients from 2010 to 2011, elderly women received an AVF less often than men, with an adjusted odds ratio of 0.57, and had higher rates of unsuccessful and assisted AVF use, with a hazard ratio of 1.46. Gender Disparities Vascular 2019 This finding should prompt closer review of referral timing, vessel mapping, access type, cannulation planning, and early follow-up in older women rather than acceptance of a catheter-dependent pathway as inevitable.

The access sequence should be written as a decision tree. A suitable distal AVF may be first when the patient has time, anatomy, and a Life-Plan favoring long-term autogenous access. An upper-arm AVF, including brachiobasilic transposition, may be selected when distal targets are poor and the patient can tolerate the operation. An AVG may be preferable when catheter exposure must be shortened, when fistula maturation probability is low, or when previous fistula attempts have already consumed time and sites. A catheter may be necessary as a bridge, but the plan should state what event will end catheter dependence. KDOQI clinical practice 2019 · AVF 2025 · Impact evolving strategies 2025 · AVF vs graft outcomes meta-analysis 2025 · Outcomes brachiocephalic fistulas 2009

60.4Creation technique, early failure, and complication prevention

Access creation should be performed with the same Life-Plan discipline used in selection. The operation is not simply the construction of a single anastomosis; it is the first step in creating a cannulatable circuit that must mature, be safely needled, and remain available long enough to justify the chosen site. The HFM cohort is a useful reminder that unassisted maturation and longer-term functional patency are separate outcomes, and that remedial interventions were discouraged within the first 6 weeks in that study, providing a benchmark for early postoperative expectations. Arteriovenous Fistula Maturation 2021

Choice of anesthesia may influence maturation and should be decided before the patient enters the operating room. In the HFM secondary analysis, regional or local anesthesia was associated with higher unassisted maturation than general anesthesia, with rates of 53.1% versus 40.3%, and the association persisted after adjustment for patient factors and fistula type. For the surgeon, the practical implication is to involve anesthesia early, particularly when the patient’s physiology allows a regional or local approach and when marginal vessel quality makes every modifiable maturation factor important. Association between anaesthesia 2022

Early postoperative ultrasound should focus on the parameters that predict clinical maturation. In the HFM cohort, AVF blood flow, vein diameter, and vein depth measured at 1 day, 2 weeks, and 6 weeks were independent predictors of clinical maturation. Prediction Arteriovenous Fistula 2018 The surgeon should therefore interpret early follow-up around these three measurements rather than relying only on the presence of a thrill, because a palpable access may still be too deep, too small, or too low-flow to become reliably cannulatable.

Percutaneous endovascular AVF creation is an accepted consideration within contemporary access planning when anatomy is suitable and the access team can support follow-up. In the Ellipsys pivotal multicenter single-arm trial, 107 patients at 5 sites underwent ultrasound-guided proximal radial artery-to-perforating-vein fistula creation using a thermal-resistance anastomosis device. The primary endpoints were brachial artery flow of at least 500 mL/min and target vein diameter of at least 4 mm in more than 49% of patients, without device-related complications at 90 days. Pivotal Multicenter Trial 2018 · KDOQI 2019

The pivotal Ellipsys results show why the technique is attractive in selected patients. Fused anastomoses were achieved in 95% of cases, the primary flow and diameter endpoints were met in 86%, and cumulative patency was 91.6%, 89.3%, and 86.7% at 90, 180, and 360 days, with no major device-attributed adverse events. These results support percutaneous AVF as a legitimate option, but they should be paired with strict anatomic screening because only about half of limbs in an ultrasound-mapping screen met minimum Ellipsys eligibility. Pivotal Multicenter Trial 2018 · Feasibility arteriovenous fistula 2020

Additional percutaneous AVF data support high technical success but also reinforce the need for programmatic follow-up. A 16-patient single-center Ellipsys series reported 100% technical success, mean operation time of 24.2 minutes, mean fistula flow of 681 mL/min, and 30-day primary patency of 94%, with 13 of 15 patients meeting hemodialysis-ready flow criteria at first follow-up. Technical aspects percutaneous 2023 An aggregated and individual-participant-data meta-analysis of 1863 patients across 18 percutaneous endovascular AVF studies reported technical success of 97.08%, maturation of 82.13%, primary patency of 87.27%, secondary patency of 79.94%, and abandonment of 15.58%, with broadly comparable mid-term patency to surgical AVF. Systematic review individual

Novel maturation adjuncts should be presented as investigational or adjunctive unless the evidence supports routine use. In a sheep model, photochemical balloon-catheter treatment of the cephalic vein with a photoactivatable dimer increased post-fistula lumen diameter and medial cross-sectional area at 1 week and increased smooth-muscle cell proliferation without intimal hyperplasia, identifying the technique as a candidate approach rather than an established human standard. Photochemically Aided Arteriovenous 2023 Far-infrared therapy, by contrast, has pooled clinical data showing favorable risk ratios for one-year unassisted patency, AVF occlusion, and surgical intervention, but implementation should still be aligned with local access pathways and follow-up capacity. Far-infrared therapy 2025

Cannulation planning starts at creation because the access must ultimately serve dialysis nurses and patients, not just satisfy intraoperative patency. A systematic review of seven studies on AVF cannulation needle direction and distance found uncertain effects on KT/V and access recirculation overall; non-randomized data suggested retrograde needle direction lowered KT/V and antegrade direction lowered recirculation, but randomized data did not confirm these trends. Needle Direction Distance 2023 The practical lesson is that cannulation protocols should be standardized and monitored locally, while avoiding overconfident claims from weak or inconsistent evidence.

Early failure prevention also requires restraint. KDOQI 2019 advises against routine preemptive angioplasty of asymptomatic stenoses identified only by ultrasound surveillance when there are no clinical indicators of access dysfunction. KDOQI 2019 This is particularly important for surgeons and interventionists who encounter early ultrasound abnormalities: a lesion should be interpreted in the context of flow, vein diameter, depth, cannulation readiness, dialysis performance, and the patient’s access plan rather than treated solely because it is visible. Prediction Arteriovenous Fistula 2018

When a clinically significant stenosis does require treatment, the evidence base should inform expectations rather than substitute for judgment. A meta-analysis of three studies and 180 patients comparing cutting balloon with high-pressure balloon angioplasty for AVF stenosis showed superior 6-month primary lesion patency with cutting balloon, with a risk ratio of 1.45, but no significant difference in technical or clinical success. Efficacy cutting balloon 2024 This supports considering device choice in recurrent or resistant lesions, while leaving detailed surveillance and failure-management protocols to the access-maintenance pathway. KDOQI 2019

60.5Patient-centered sequencing and transition to surveillance

The end of access creation is the beginning of access stewardship. Follow-up should confirm whether the chosen access is moving toward the Life-Plan goal: safe catheter removal, reliable cannulation, preservation of future sites, and avoidance of unnecessary procedures. KDOQI’s patient-centered framework is useful here because it treats surveillance, complication management, imaging, and access choice as linked decisions rather than isolated episodes. KDOQI clinical practice 2019

The first follow-up decision is whether the access is progressing as expected for the selected pathway. For an AVF, this means assessing clinical usability and, when indicated, ultrasound measures of flow, diameter, and depth; for an AVG, it means confirming that the graft strategy is aligned with cannulation timing, infection avoidance, and anticipated maintenance; for a catheter bridge, it means documenting the event that will allow catheter removal. KDOQI’s access targets and the UK Kidney Association’s graded planning recommendations both support this structured transition from creation to surveillance. UK Kidney Association 2025 · KDOQI clinical practice 2019 · UKKA 2025

Escalation should be triggered by clinical dysfunction, failure to progress, or mismatch between the access and the patient’s dialysis need, not by imaging alone. KDOQI specifically advises against routine preemptive angioplasty of asymptomatic stenoses identified only by ultrasound surveillance without clinical indicators of access dysfunction. KDOQI 2019 The surgeon should therefore resist treating a surveillance image in isolation and instead ask whether the finding changes cannulation, dialysis adequacy, thrombosis risk, catheter dependence, or the next step in the Life-Plan.

A mature access program should audit process failures as carefully as technical failures. The barriers to higher AVF prevalence include referral timing, the type of fistula attempted, patient demographics, clinician preference, and vessel anatomy; these are program-level issues that require nephrology, surgery, dialysis nursing, anesthesia, and interventional collaboration. Increasing arteriovenous fistulas 2002 Safe vascular access guidance similarly emphasizes team responsiveness, device selection, ultrasound and tip confirmation, maintenance, complication response, and training, all of which influence whether the patient reaches functional dialysis access. Association Anaesthetists guidelines 2025

Surveillance findings should also feed back into future access planning. A failed distal AVF with poor early flow and inadequate vein enlargement should not automatically lead to another low-probability distal attempt; the next plan may be upper-arm autogenous access, AVG creation, or catheter-bridged transition depending on the patient’s Life-Plan, vessel map, and dialysis urgency. Association preoperative vein 2022 Preoperative mapping data from large registries and meta-analytic evidence supporting ultrasound mapping should be used again at this stage, because the relevant anatomy and available options may have changed after the first operation. KDOQI clinical practice 2019 · Pre-operative ultrasound mapping 2023 · Preop US Mapping 2024

Equity should be part of surveillance and sequencing. Elderly women who initiate dialysis with a catheter have been shown to receive AVFs less often and to experience more unsuccessful and assisted AVF use than men, so a surveillance program should track not only patency but also who receives access attempts, who remains catheter-dependent, who requires assisted use, and who cycles through repeated failed procedures. This is a clinical quality issue because the wrong sequence can consume time, expose the patient to catheter risk, and erode future access options. KDOQI clinical practice 2019 · Gender Disparities Vascular 2019

Catheter dependence should be treated as an active surveillance outcome. The Romanian registry showed that only 20% of incident hemodialysis patients started with an AVF, while 80% started with temporary or tunneled catheters, and catheter initiation carried more than double the mortality hazard. Although registry data do not prove that every catheter start is avoidable, they make clear that timely access planning, rapid escalation after nonmaturation, and explicit catheter-exit criteria are central to quality vascular access care. Patterns outcomes vascular 2025

The final surgical responsibility is to leave the next clinician with a usable roadmap. After creation, the record should state the access type and location, whether the access is expected to mature without intervention, what clinical or ultrasound findings will prompt reassessment, whether asymptomatic stenosis should be observed rather than treated, when the dialysis unit may begin cannulation assessment, and what the next access option will be if the present access fails. This preserves the patient-centered Life-Plan and prevents the access pathway from becoming a series of disconnected procedures. UK Kidney Association 2025 · KDOQI clinical practice 2019 · UKKA 2025 · KDOQI 2019