Vascular access in the 21st century.

Worldwide, aged diabetic patients represent the most rapidly growing group of patients treated for endstage renal disease (ESRD). Pre-existing arterial as well as venous problems have led to a pessimistic view on the creation of vascular access in the future. In addition, more and more patients undergo hemodialysis therapy for twenty or thirty years with obvious vascular wastage. Personal experience in the interdisciplinary field of vascular access covering nephrology, vascular surgery and radiology clearly show that history is a good teacher. Since the introduction of the surgically created arterio-venous fistula by Brescia and Cimino in 1966, only minor progress has been seen; widespread use of different graft materials has produced mainly disappointing results, thus contributing to more temporary or permanent central venous catheters. Despite better catheter technology, essential problems like infection and thrombosis have not changed. The challenge for the 21st century is to find strategies and solutions to face these deteriorated conditions. The factors contributing to adequate vascular access are: an individually tailored approach with clear preference for native vessels, respecting basic hemodynamic rules, analysing past failures, combining careful preoperative investigations and meticulous surgical technique; continuous surveillance of fistula function and early, elective revision to prolong the lifespan of vascular access. An interdisciplinary team will be essential to achieve this goal.