Should arteriovenous fistulas and synthetic grafts undergo surveillance with pre-emptive correction of stenosis?

This Practice Point commentary discusses Tonelli et al.'s systematic review and meta-analysis of randomized controlled trials that evaluated surveillance of hemodialysis accesses. Tonelli et al. identified studies that used access blood-flow measurements or duplex ultrasound, and found only four publications of native fistulas and seven of synthetic grafts that met their criteria. Study quality was not high and statistical power was generally low. Tonelli et al. found that fistula surveillance reduced the risk of thrombosis without prolonging fistula life, and that graft surveillance showed no benefit. This commentary discusses why this small meta-analysis might have been biased towards not finding a benefit for stenosis surveillance of grafts by duplex ultrasound. Larger multicenter randomized trials are needed to establish the role of surveillance. Tonelli et al.'s study will encourage reconsideration of the current recommendation in clinical practice guidelines that grafts should undergo routine flow surveillance.