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Review
. 2021 Jan;44(1):3-16.
doi: 10.1177/0391398820922231. Epub 2020 May 22.

Arteriovenous access in hemodialysis: A multidisciplinary perspective for future solutions

Bernd Stegmayr  1 , Christian Willems  2 , Thomas Groth  2   3 , Albino Martins  4 , Nuno M Neves  4 , Khosrow Mottaghy  5 , Andrea Remuzzi  6 , Beat Walpoth  7
Affiliations
Review

Arteriovenous access in hemodialysis: A multidisciplinary perspective for future solutions

Bernd Stegmayr et al. Int J Artif Organs. 2021 Jan.

Abstract

In hemodialysis, vascular access is a key issue. The preferred access is an arteriovenous fistula on the non-dominant lower arm. If the natural vessels are insufficient for such access, the insertion of a synthetic vascular graft between artery and vein is an option to construct an arteriovenous shunt for punctures. In emergency situations and especially in elderly with narrow and atherosclerotic vessels, a cuffed double-lumen catheter is placed in a larger vein for chronic use. The latter option constitutes a greater risk for infections while arteriovenous fistula and arteriovenous shunt can fail due to stenosis, thrombosis, or infections. This review will recapitulate the vast and interdisciplinary scenario that characterizes hemodialysis vascular access creation and function, since adequate access management must be based on knowledge of the state of the art and on future perspectives. We also discuss recent developments to improve arteriovenous fistula creation and patency, the blood compatibility of arteriovenous shunt, needs to avoid infections, and potential development of tissue engineering applications in hemodialysis vascular access. The ultimate goal is to spread more knowledge in a critical area of medicine that is importantly affecting medical costs of renal replacement therapies and patients' quality of life.

Keywords: Arteriovenous access; apheresis and detoxification techniques; arterial grafts; artificial kidney; biomaterial surface characterization; blood–material interactions; dialysis access; hemodialysis; polymer membranes; tissue engineering; vascular grafts; wall shear stress.

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Conflict of interest statement

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
If a cutting needle is used in an AVF or AVS with the edge downward and against the blood flow direction, there will be a flap of the vessel wall that will obstruct the vessel and keep an open area at the site of injection that increases the risk of hematoma. If the edge is turned up-side down, the flap of the vessel will tighten as a lid. Locating the needle with the flat side down during HD minimizes the risk for puncture of the opposite wall.
Figure 2.
Figure 2.
Change in cardiac output in relation to AVF blood flow in patients of either 50 kg BW and 161 cm height (open square, hatched line) or 90 kg BW and 185 cm (open triangle and filled line). Calculations are based on Jegier et al.
Figure 3.
Figure 3.
A flow greater than 120 mL/min at the time of surgery results in better maturation rate of the fistula as shown by Saucy et al. Blood flow (in mL/min) in functioning (black box) and non-functioning radiocephalic AVF (white box).
Figure 4.
Figure 4.
Removed graft visualizes holes after repeated punctures caused by HD access.
Figure 5.
Figure 5.
Tissue engineering approaches for developing biological and biogenic vascular grafts for AVS.
See this image and copyright information in PMC

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