Part 11/Chapter 60/7-min read

Hemodialysis Access Planning, Selection, and Creation

Hemodialysis access planned around the patient's ESKD Life-Plan rather than around the surgeon's preferred conduit: life expectancy, comorbidity, expected dialysis duration, transplant likelihood, and remaining venous options. The chapter frames AVF, AVG, and tunnelled catheter selection and creation.

Edited by Tal M. Hörer MD, PhD · David T. McGreevy MD, PhD·Reviewed ·6 sections · 30 references

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Planning conference: A practical planning-room conversation: anatomy, device or operative choices, surveillance, complications, and decision boundaries.

General medical education, not patient-specific advice.

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Definition and principles of access planning

Hemodialysis access planning is governed by the End-Stage Kidney Disease (ESKD) Life-Plan, an individualized sequence matching access options to life expectancy, comorbidity, and dialysis trajectory . Planning spans the whole kidney-replacement trajectory, including peritoneal dialysis and pre-emptive transplantation and not only the immediate fistula, so vessel preservation protects future access sites. Timing anchors to anticipated dialysis need rather than a fixed eGFR trigger. Contemporary guidelines replace universal "fistula-first" mandates with patient-centered targets for arteriovenous fistulas (AVFs), arteriovenous grafts (AVGs), and central venous catheters (CVCs) .

Access provision is a multidisciplinary process rather than an isolated surgical procedure. Optimal vascular access requires coordinated nephrology, vascular surgery, anesthesia, and dialysis-nursing engagement to manage referral timing, device selection, vessel mapping, and access creation .

Preoperative assessment and vessel mapping

Routine preoperative ultrasound mapping is the standard of care for access planning. A meta-analysis of 18 studies supports routine mapping over selective use, demonstrating a reduction in primary AVF failure with an RCT-pooled risk ratio of 0.37 . Registry data (Vascular Quality Initiative) report over 85% utilization of preoperative mapping for patients undergoing AVF or AVG placement .

Physical examination remains necessary to identify arterial insufficiency, visible superficial veins, prior incisions, and limb dominance, complementing reproducible ultrasound measurements of vein diameter, continuity, depth, compressibility, and arterial inflow.

Patient-level risk factors strongly predict the failure of an access to mature, independent of vessel mapping. The REDUCE FTM I prediction rule identifies four primary risk factors for failure to mature:

  • Peripheral vascular disease (odds ratio 2.97).
  • Coronary artery disease (odds ratio 2.83).
  • Age >= 65 years (odds ratio 2.23).
  • Non-white race (odds ratio 0.43 for white race) .

Access selection and sequencing

The access sequence prioritizes preserving future sites while delivering a functional circuit within the required clinical timeframe. Autogenous AVFs offer superior one-year primary (odds ratio 1.61), primary-assisted (odds ratio 1.69), and secondary patency compared with AVGs . Catheters carry elevated mortality hazards and are reserved as temporary bridges or last-resort long-term options for patients lacking viable surgical targets . In the nationwide registry, only 20% of patients began dialysis with a functioning AVF, catheter-based initiation carried more than twice the mortality hazard of a fistula, and median AVF survival was 39.1 months.

DiagnosticHemodialysis access selection
Distal radiocephalic AVF
Anatomic or clinical criteria
Patent wrist vessels, time permitting maturation
Strategic role
First-line autogenous option to preserve proximal sites. 1-year primary patency 68.4%, 3-year primary patency 55.10%.
Citation
Upper-arm brachiobasilic AVF
Anatomic or clinical criteria
Poor cephalic anatomy, high risk of early brachiocephalic failure
Strategic role
Preferred upper-arm alternative. 15% primary failure vs 38% for brachiocephalic AVFs.
Citation
Upper-arm brachiocephalic AVF
Anatomic or clinical criteria
Adequate cephalic vein
Strategic role
Standard upper-arm autogenous option; carries 2.76-fold higher primary failure hazard than brachiobasilic transposition.
Citation
Percutaneous endovascular AVF
Anatomic or clinical criteria
Patent proximal radial artery and adjacent perforator vein both >= 2 mm and <= 1.5 mm apart
Strategic role
Alternative autogenous access. Requires strict anatomic screening (approximately 50% of limbs eligible).
Citation
Arteriovenous graft (AVG)
Anatomic or clinical criteria
Poor autogenous targets, limited life expectancy, need to minimize catheter bridging
Strategic role
Durable intermediate option. Not a failed AVF, but a distinct strategy.
Citation
  1. Assess Life-Plan, dialysis urgency, and vessel map.
  2. Consider percutaneous AVF if strict anatomic criteria are met.
  3. Select a distal radiocephalic AVF if vessels are suitable and maturation time permits.
  4. Choose an upper-arm AVF (brachiobasilic or brachiocephalic) based on anatomy and failure risk.
  5. Proceed to an AVG if autogenous maturation probability is low or catheter time must be minimized.
  6. Place a CVC only as a bridge or when surgical options are exhausted.

Creation technique and maturation

Anesthesia choice influences autogenous maturation. Regional or local anesthesia is associated with significantly higher unassisted AVF maturation rates than general anesthesia (53.1% vs 40.3%), supporting regional techniques when physiologic and technical factors allow .

Postoperative ultrasound defines early maturation progress. In the Hemodialysis Fistula Maturation (HFM) cohort, AVF blood flow, vein diameter, and vein depth measured at 1 day, 2 weeks, and 6 weeks independently predict clinical maturation, providing stronger prognostic value than physical examination or case-mix factors alone . The 2019 KDOQI guideline defines functional maturation as a fistula that reliably delivers the prescribed dialysis with two needles in more than two-thirds of sessions across a 4-week period; assess clinical maturation by 4 to 6 weeks postoperatively and refer early when the access is not maturing. No minimum vessel diameter mandates fistula creation, though arteries or veins under roughly 2 mm warrant careful feasibility assessment .

Percutaneous endovascular AVF creation (e.g., using thermal-resistance anastomosis) delivers high technical success in suitably selected patients. In a pivotal trial, fused anastomoses were achieved in 95% of cases, and primary flow (>= 500 mL/min) and diameter (>= 4 mm) endpoints were met in 86% . An individual-participant-data meta-analysis confirms 97% technical success and 82.1% maturation with mid-term patency comparable to surgical AVFs .

Pharmacologic adjuncts improve AVG outcomes. In patients with new grafts, extended-release dipyridamole (200 mg) plus aspirin (25 mg) twice daily improves 1-year primary unassisted patency to 23%, compared with 13% for placebo . Cannulation timing separates graft types. Standard ePTFE grafts should not be cannulated until swelling resolves and the graft incorporates, typically 2 to 4 weeks after creation; early-cannulation grafts (Acuseal, Flixene) accept needles within 24 to 72 hours and can shorten or eliminate catheter bridging .

Surveillance and complication prevention

Post-creation surveillance tracks progress toward cannulation, identifies failure to progress, and dictates the timing of catheter removal. Routine preemptive angioplasty of asymptomatic stenoses identified solely by ultrasound is not recommended in the absence of clinical indicators of access dysfunction .

When clinically significant AVF stenosis requires treatment, cutting-balloon angioplasty demonstrates superior 6-month primary lesion patency over high-pressure balloon angioplasty (risk ratio 1.45), although overall clinical success rates remain similar .

Access pathways are subject to systemic disparities that influence surveillance. Elderly women initiating dialysis receive AVFs less often than men (adjusted odds ratio 0.57) and experience higher rates of unsuccessful or assisted AVF use (hazard ratio 1.46). This mandates rigorous monitoring of referral, mapping, and catheter-dependence rates in older female cohorts . Geographic variation is also pronounced; historical data reveal 21-fold higher AVF utilization in European facilities compared with US facilities after adjustment for patient characteristics .

Areas of controversy

Optimal AVF cannulation needle direction is debated; non-randomized data suggest retrograde direction may lower KT/V and antegrade direction may lower recirculation, but randomized trials do not confirm these effects .

Maturation adjuncts such as photochemical balloon-catheter treatments and far-infrared therapy show experimental and pooled clinical promise for reducing intimal hyperplasia and improving unassisted patency, but remain investigational rather than standard care .

Biologic predictors, including mineral metabolism markers (FGF-23, PTH, calcium, phosphate) and bioinformatic inflammatory signatures, correlate with vein remodeling and maturation but are not yet validated as routine selection tools .

Benchtop surveillance technologies, such as novel 3D ultrasound devices (EchoSure) operated by novices, achieve volume-flow accuracy comparable to expert duplex ultrasound, but their role in replacing formal vascular laboratory surveillance is not established .

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