Innovations in vascular access for hemodialysis.

Worldwide, hemodialysis remains the prevalent dialysis modality for more than 2 million patients who require well-functioning vascular access for this procedure. Creation of an arteriovenous fistula for long-term hemodialysis was the first innovation since the Scribner shunt and was followed by the development of an arteriovenous graft and catheter. Bioengineered vessels were developed during the last century, but this field has been energized by recent technology relating to the creation of human vessels. Novel endovascular techniques for creating an arteriovenous fistula may resolve some of the logistical issues involved in obtaining a timely arteriovenous fistula. Treatment of access stenosis, infection, and thrombosis has remained suboptimal, and innovative technologies are evolving. Many new approaches are now targeting the biological and mechanical aspects of vascular access, such as creation and maturation of arterial and venous anastomoses, development of a biological conduit for outflow, and negotiating the problems of central vein stenosis. Importantly, processes of access care that have long focused on arteriovenous fistulas are now recognizing the new paradigm, providing a complementary niche to arteriovenous grafts and dialysis catheters in the algorithm for individualized access placement. Cumulatively, to the credit of the multidisciplinary team approach, the long overdue focus on the very existential issue of vascular access for hemodialysis is being approached with newfound evidence-based enthusiasm as the vexing challenges related to regulations and reimbursement in hemodialysis persist. Patient choice and experience, often missed and ignored in the challenging management of an end-stage organ failure, need to stay central as we focus on patient-centered care of vascular access.