[When the native arterial-venous fistula cannot be performed: graft or catheter? A comment]

Abstract

In Italy, the logistics for the creation of a vascular access are not well arranged. Numerous specialists are involved, mostly on a voluntary basis: they are those who ''know how to make the vascular access'', and have earned the title on the battlefield. When a native arteriovenous fistula, the gold standard, cannot be created, different solutions may prevail, depending on the local availability of specific skills. The use of vascular grafts for vascular access is not common in Italy. Grafts are mainly performed by vascular surgeons or, less frequently, by nephrologists with specific expertise in centers of excellence. By contrast, venous catheterization as an emergency access for dialysis is very common in Italian nephrology and dialysis centers. In optimal operating conditions, when both options are available and fistula creation and management are feasible, the choice of a graft fistula would be almost obligatory, although there are exceptions. Usually, the need urges the renal physician to favor compromise solutions: a compromise between physician and patient, between who performs the vascular access and who manages dialysis, between the patient's right to express a choice and acute disease that requires a quick solution and positive outcome. We need a revision (or revolution?) of vascular access creation and management that will lead to a choice between venous catheter or vascular graft that is balanced and useful for the patient.