Hemodialysis Vascular Access: A Historical Perspective on Access Promotion, Barriers, and Lessons for the Future

Abstract

This review describes the history of vascular access for hemodialysis (HD) over the past 8 decades. Reliable, repeatable vascular access for outpatient HD began in the 1960s with the Quinton-Scribner shunt. This was followed by the autologous Brecia-Cimino radial-cephalic arteriovenous fistula (AVF), which dominated HD vascular access for the next 20 years. Delayed referral and the requirement of 1.5-3 months for AVF maturation led to the development of and increasing dependence on synthetic arteriovenous grafts (AVGs) and tunneled central venous catheters, both of which have higher thrombosis and infection risks than AVFs. The use of AVGs and tunneled central venous catheters increased progressively to the point that, in 1997, the first evidence-based clinical practice guidelines for HD vascular access recommended that they only be used if a functioning AVF could not be established. Efforts to promote AVF use in the United States during the past 2 decades doubled their prevalence; however, recent practice guidelines acknowledge that not all patients receiving HD are ideally suited for an AVF. Nonetheless, improved referral for AVF placement before dialysis initiation and improved conversion of failing AVGs to AVFs may increase AVF use among patients in whom they are appropriate.

Keywords: Catheter; fistula; graft; hemodialysis; vascular access.

Figure 1

Timeline of hemodialysis vascular access. Dark blue arrows represent the timing of NKF-KDOQI vascular access clinical practice guidelines. Brown arrow reflects the formation of National Medical Care, the first for profit dialysis provider. Light blue arrow points to passage of 1972 Public law 92-603, section 2991 authorizing Medicare payments for treatment of patients with kidney failure. Green arrow reflects establishment of the U.S. Renal Data System. Orange arrow reflects establishment of ESRD Clinical Performance Measures Project. Red arrow reflects onset of bundled payment for dialysis. Abbreviations: PTFE, polytetrafluoroethylene; AVF, arteriovenous fistula; AVG, arteriovenous graft; TDC, tunneled dialysis catheter; HeRO, hemodialysis reliable outflow graft. Figure adapted from Hassanein M et al.

Figure 2

The Quinton-Scribner shunt.