Secondary hemodialysis arteriovenous fistula
- Gerald A Beathard, MD, PhD
Gerald A Beathard, MD, PhD
- Clinical Professor
- University of Texas Medical Branch
- Section Editors
- David L Cull, MD
David L Cull, MD
- Section Editor — Arterial and Venous Access
- Clinical Professor, Department of Surgery
- University of South Carolina School of Medicine
- Jeffrey S Berns, MD
Jeffrey S Berns, MD
- Editor-in-Chief — Nephrology
- Section Editor — Dialysis
- Professor of Medicine
- Perelman School of Medicine at the University of Pennsylvania
Among the three principal forms of chronic vascular access available for hemodialysis, the arteriovenous (AV) fistula is most desirable because it has the best long-term primary patency rate, requires the fewest interventions, and is associated with the lowest morbidity and mortality when compared with the alternatives [1-5]. The rationale for the preference of an AV fistula rather than other forms of hemodialysis access is discussed separately. (See "Overview of chronic hemodialysis vascular access", section on 'Comparison of AV fistulas and AV grafts' and "Creating an arteriovenous fistula for hemodialysis", section on 'General characteristics and benefits'.)
We agree with Fistula First Breakthrough Initiative (FFBI) Change Concept #3 that every potential hemodialysis patient should be first evaluated for an AV fistula , which has become the standard for clinical practice. In spite of this initiative, approximately 30 percent of patients receiving hemodialysis in the United States do so with an AV graft, which may be appropriate under some circumstances, such as in the patient without any suitable vessels or the patient with a limited life expectancy (ie, palliative dialysis) .
Any patient using an AV graft should also be considered a potential candidate for conversion to an AV fistula if the graft fails, which is referred to as a secondary arteriovenous fistula (SAVF). This is defined as an AV fistula that is created following the failure of a previous AV access (generally lower arm) and includes either an AV graft (most commonly) or an AV fistula.
The options, evaluation of the patient, and choice of secondary hemodialysis access are reviewed here. Primary hemodialysis AV access, including maturation and initial management of failed primary AV access, is discussed separately. (See "Maturation and evaluation of the newly created hemodialysis arteriovenous fistula" and "Primary failure of the hemodialysis arteriovenous fistula".)
The concept of a secondary arteriovenous fistula (SAVF) is very important, given the known issues and complications associated with arteriovenous (AV) fistulas and, to an even greater extent, AV grafts. In the past, a SAVF was defined as an AV fistula constructed using the outflow vein of an AV graft. The definition has been expanded to include any AV fistula constructed following the failure of a prior AV access, regardless of whether the primary access was an AV fistula or AV graft. Two types of SAVF are defined. Although both are referred to as an SAVF, they differ conceptually. Each is described below.
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