The three principal forms of chronic vascular access for hemodialysis are native arteriovenous fistulas (native AVFs), arteriovenous shunts using graft material (AV graft), and tunnelled double-lumen catheters. Of these, the native AVF is preferred for long-term hemodialysis vascular access since it has the best long-term primary patency rate, requires the fewest interventions of any type of access, and most importantly, AVFs are associated with the lowest incidence of morbidity and mortality [1-5]. The National Kidney Foundation Kidney Disease Quality Outcomes Initiative (NKF-KDOQI) clinical practice guidelines suggest a goal prevalence rate for native AVF of 65 percent . To achieve these goals, disparities in the successful creation of native AVF need to be overcome. In most studies, fewer AV fistulas are reported in female than in male hemodialysis patients [7-11], and in African-American compared with non-African-American hemodialysis patients [7-12]. The explanation for gender and racial differences is not totally clear; however, it has been shown that there is a greater risk of primary failure in both women and African-Americans [13,14].
The creation of native AVFs for hemodialysis patients is reviewed here. An overview of the different types of chronic hemodialysis access is presented separately. (See "Arteriovenous fistulas and grafts for chronic hemodialysis access".)
GENERAL CHARACTERISTICS AND BENEFITS
Benefits — Native arteriovenous fistulas (AVFs) are preferred over other forms of chronic hemodialysis access and we recommend placement of an AVF rather than an AV graft or tunnelled double-lumen central catheter, whenever possible. However, the temptation to create an arteriovenous fistula to satisfy the fistula-first initiative in patients with inadequate vessels should be resisted. Overly aggressive attempts to increase AVF prevalence in patients with suboptimal anatomy leads to reduced maturation rates, and a longer duration of dialysis catheter use . (See 'Patients with inadequate vessels' below.)
The benefits of AVFs over other forms of chronic access are summarized below and discussed in detail elsewhere. (See "Arteriovenous fistulas and grafts for chronic hemodialysis access", section on 'Comparison of fistulas and grafts'.)
- AVFs are associated with decreased morbidity and mortality among hemodialysis patients compared with AV grafts and central venous catheters [16-18].
- AVFs have the superior primary patency rates, the lowest rates of thrombosis, and require the fewest secondary interventions [4,19-21].
- AVFs generally provide longer hemodialysis access survival rates [2,4,19,21-24].
- The total number of interventions during the life of the access is considerably lower for AVFs compared with AV grafts [4,19,23].
- AVFs have lower rates of infection than AV grafts and significantly lower infection rates compared with percutaneous catheters [5,25].
- Patients with AVFs have lower hospitalization rates than patients with AV grafts or catheters .
- The cost of implantation and maintenance of AVFs is the lowest of the three types of access [4,6,8].