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Preoperative evaluation and postoperative care are integral parts of successful hemodialysis access surgery [1]. Clinical information pertinent to vascular access selection and creation are essential to proper planning and operative success. Likewise, organized postoperative care is required in order to minimize surgical complications and achieve a functional dialysis access, as well as avoiding unnecessary futile procedures that would not yield to a functional dialysis access.

Dialysis vascular access is an important “bridge” that connects the patient to the hemodialysis machine. It is often considered the “Achilles Heel” of hemodialysis due to the potential complications that may arise. Broadly, dialysis can be performed via an arteriovenous fistula (AVF), arteriovenous graft (AVG) or a catheter (Tunneled or non-tunneled). The advantages and disadvantages of the different types of vascular access are described in this chapter.

Distal revascularization and interval ligation are performed to treat steal syndrome in patients with hemodialysis access in an attempt to preserve the fistula and avoid its ligation. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

Fistula first initiative is the recommended guideline for hemodialysis access. The creation of distal radiocephalic fistula often is not an option; additionally, non-maturation of created fistula leads to use of arm vessels which increases the risk of complications. Proximal forearm fistula even though overlooked may be a viable option with reasonably good outcomes and patency. The case describes proximal radiocephalic fistula (pRCF), ulnar-basilic AVF (UBAVF), and transposed radio-basilic fistula (tRBF) of the forearm and techniques and outcomes.

Arteriovenous hemodialysis catheters have lower rates of primary and secondary patency than autologous arteriovenous fistulas in most patients. While emphasis has been placed on de novo construction of arteriovenous fistulae, grafts are still placed for primary access in a large population of end-stage renal disease placements. Unfortunately, once these grafts fail, patients are often left with no peripheral hemodialysis access and require central venous catheter placement. Construction of secondary arteriovenous fistulae prior to graft failure obviates the need for this period of hemodialysis catheter placement.

Vascular access in long-term hemodialysis patients is an evolving and increasingly complex situation facing vascular access surgeons. Central stenosis from repeated and long-term catheter use is the primary complication necessitating new techniques and technology to provide reliable and durable long-term internal access for these patients. This chapter will focus on several new advancements and highlight preexisting, but less commonly used, techniques to provide long-term hemodialysis access in this challenging patient population.

Because of the high availability and easy accessibility of medical service, hemodialysis (HD) continues to be the most commonly utilized renal replacement therapy in Taiwan. Among the 67,665 prevalent ESRD patients, more than 60,000 of patients (89.7 %) undergoing in-center HD twice to three times per week. This chapter discusses the management of ESRD and the hemodialysis experience in Taiwan.

Procedures to establish hemodialysis access are common and increasing in frequency as more and more patients are diagnosed with advanced chronic kidney disease and end-stage renal disease. This chapter will describe the essentials of anesthesia management for hemodialysis access surgery: choice of anesthesia method, preanesthesia preparation, and intraoperative and postoperative management.

Outcomes research evolved in the 1970s as a method to evaluate and improve patient care delivery. Recent efforts by CMS to identify trends in vascular access for end-stage renal disease (ESRD) lead to the Fistula First Catheter Last (FFCL) initiative aimed at increasing incident and prevalent arteriovenous fistula usage. There is a significant protective effect from autogenous conduit employed as the access modality for renal replacement therapy. Surgeons demonstrate varying results establishing and maintaining fistulas. Current efforts to create large registry reports and level 1 evidence aimed at guiding this field are ongoing. This chapter describes the science associated with reporting health and procedural outcomes, particularly vascular access for end-stage renal disease patients.

Greater than 60 % of patients with end-stage renal disease initiate dialysis by a central venous catheter, and approximately 20 % of all dialysis patients are undergoing dialysis via a central venous catheter at any point in time. Given the widespread use of central venous catheters for dialysis access, this chapter will serve as a comprehensive overview of the topic, including a review of both tunneled and non-tunneled catheters, site selection, techniques for placement, and management of device-related complications.

Although the past five decades have witnessed dramatic transformations in dialysis technologies and health-care infrastructure, the fundamental dependence of each patient undergoing maintenance hemodialysis on long-term reliable vascular access has remained unchanged. The past decade in the United States has witnessed the development and implementation of a number of vascular access initiatives led by a variety of different stakeholders focused on increasing the prevalence of arteriovenous fistulas and limiting the use of central venous catheters in hemodialysis patients. These have included the Fistula First Initiative most prominently and also include the Centers for Medicare and Medicaid Services End-Stage Renal Disease Quality Incentive Program, the Healthy People 2020 campaign, and the Renal Physicians Association Vascular Access Initiative. Coinciding with implementation of these initiatives has been an acceleration of a marked transition from the dominant use of arteriovenous grafts to that of arteriovenous fistulas among individuals in the United States undergoing maintenance hemodialysis. In contrast to the distribution of vascular access types used by prevalent patients, the distribution of access use by patients starting maintenance hemodialysis has shown remarkably little change over the past decade. Over the past 3–4 years, recognition of the plateauing proportion of prevalent hemodialysis patients using fistulas as well as the persistently and unacceptably high proportion of patients starting dialysis with catheters has led to calls to reorient the Fistula First Initiative to include a renewed emphasis on primarily discouraging the long-term use of central venous catheters.

Ultrasound is a valuable tool for assessing patients at all phases of dialysis access creation and maintenance. This chapter specifically covers point-of-care (POC) applications and focuses on clinician-performed ultrasound examinations for the purpose of guiding decision-making and interventions.

Access surgeons face multiple obstacles in dealing with patients with active intravenous drug-use addictions. Lack of adequate superficial veins, medical noncompliance, associated psychiatric illness, and needs for durable-functioning access are some of the issues that need to be addressed when dealing with this unique patient population.

The radiocephalic and brachiocephalic autogenous access approaches are first-line options for dialysis access and listed as “preferred” access by the National Kidney Foundation Dialysis Outcome Quality Initiative (K/DOQI) most recent 2006 guidelines. Both have superior long-term patency to prosthetic grafts in meta-analyses. This chapter focuses on direct anastomosis cephalic vein hemodialysis access, techniques, patency, and outcomes.

Vascular access is a lifeline for end-stage renal disease patients. The National Kidney Foundation-Kidney Dialysis Outcomes Quality Initiative (NKF-KDOQI) published practice guidelines that recommend all patients with stage IV or stage V chronic kidney disease to undergo fistula creation [1]. The guidelines also included an order of preference for AV access procedures in order to preserve viable access sites. The recommendations are based on autogenous fistulas having a superior patency than prosthetic grafts and tunneled catheters, as well as fewer complications and repeat interventions. Despite these recommendations, dialysis access fails and re-intervention is needed [2, 3]. While there are often signs that an access is failing, there are many options for both avoiding and treating the access failure as it occurs.

One of the most critical aspects of planning for long-term hemodialysis (HD) is obtaining vascular access. Hemodialysis access had evolved over the years and this chapter discusses the history of hemodialysis in the USA.

This chapter details the approach to outpatient hemodialysis access monitoring and surveillance. Close monitoring, evaluation, assessment, and timely intervention can reduce the high rate of primary failure in hemodialysis access. Patient should be seen by healthcare team once every 2 weeks after the surgery, both to assess the progress of maturation process and any complications caused by the creation of access such as tissue ischemia or venous hypertension. Lack of maturation process should direct the focus on determining the cause such as channeling of blood to accessory veins, presence of stenotic area on the target vein, etc. Further diagnostic work such as sonography followed by appropriate intervention usually leads to success. Surveillance is helpful, if conducted properly and focused on the trend of any change. Static Vp and Vp/MAP ratio as well as Ap and ratio is recommended since this can be done every dialysis and does not require any special device. Serial blood flow directly or indirectly may be helpful but requires special device and staff training, and its value is controversial. Upon physical examination, pre-pump Ap and Ap/MAP ratio appear to be more sensitive for AVF and Vp more sensitive for AVG problems. Good access monitoring and surveillance program at the dialysis units and by nephrologists are invaluable in maintaining a well-functioning access.

Sequential measurements and documenting abnormal trends in flow rates or velocities over time may be helpful in identifying those access sites that should be considered for intervention. The Society for Vascular Surgery (SVS) clinical practice guidelines recommend “regular clinical monitoring to detect dysfunction” of dialysis access sites and “performing a duplex ultrasound study or contrast imaging study in accesses that display clinical signs of dysfunction or abnormal routine surveillance.” A baseline duplex ultrasound assessment of a new access site prior to first use for dialysis is valuable to verify adequate volume flow and conduit anatomy. With appropriate training, ultrasound screening for access site maturation can be performed as a “point of care” test, with referral to the vascular laboratory for a complete duplex examination when abnormalities are detected. This chapter focuses on duplex examination timing and technique in hemodialysis care.

Hemodialysis access failures affect the quality of life of ESRD patients due to the increased morbidity associated with higher numbers of hospital readmissions, invasive diagnostic studies, and open and endovascular reinterventions. The goal of this chapter is to understand the pathophysiology and management of stenosis within the hemodialysis circuit in order to better preserve functional arteriovenous access.

The most common cause of hemodialysis access dysfunction is venous stenosis resulting from intimal hyperplasia. Intimal hyperplasia is a fibromuscular thickening of the vessel wall. Its occurrence is most commonly at the perianastomotic region of arteriovenous (AV) fistulas and at the graft-vein anastomosis of arteriovenous grafts (Lee and Roy-Chaudhury, Adv Chronic Kidney Dis 16(5):329–338, 2009). It is a physiological healing response to repeated vascular injury that results in increased stenosis. It is characterized by the activation, proliferation, and migration of cells from the medial layer to the intimal layer of the blood vessel wall. Roy-Chaudhury and colleagues have proposed that the pathophysiologic development of intimal hyperplasia in vascular access is due to a series of “upstream” and “downstream” events. There is also evidence to support a genetic role. This chapter will discuss these factors that are implicated in the development and progression of intimal hyperplasia.

Hemodialysis access history is a story of pioneers in medicine who took a condition that was a once fatal and made it a chronic condition, the story of countless patients who were willing to undergo unproven therapy, and the story of early organ replacement in medicine. While the hemodialysis technology was being developed, the major obstacle to sustainable hemodialysis was the limited accessibility and durability of blood vessels. This chapter offers a historical perspective of the development of dialysis access into the 1980s.

Infection is a significant source of morbidity and mortality in the end-stage renal disease (ESRD) patients. It is the second leading cause for access loss following graft thrombosis. Likewise, infections are the second leading cause of mortality in the dialysis patients, second only to the cardiovascular mortality. The incidence of the infection is higher with the prosthetic arteriovenous grafts (AVGs) compared to autologous arteriovenous fistulae (AVF). Because of this reason, the Society for Vascular Surgery clinical practice guidelines and the KDOQI fistula first initiatives recommend the preferential use of autologous AVFs in most cases before resorting to the use of prosthetic material. This chapter discusses infection in hemodialysis access.

Hemodialysis access failures affect the quality of life of ESRD patients due to the increased morbidity associated with higher numbers of hospital readmissions, invasive diagnostic studies, and open and endovascular reinterventions. The goal of this chapter is to understand the pathophysiology and management of stenosis within the hemodialysis circuit in order to better preserve functional arteriovenous access.

This chapter focuses on the timing of hemodialysis creation and access with a discussion regarding preemptive dialysis access. Regardless of changes in strategy, the plan for preemptive AVF placement for all patients is maybe not realistic. Many patients would likely be better served with an AVG and focus on reducing the need for CVC rather than increasing the percent of AVFs. Certain patient populations (obese, female, African-American) have poor AVF maturation rates. It would seem a reasonable compromise to focus preemptive AVF placement in the population most likely to have successful maturation to make the risk-benefit ratio justifiable.

Continuous assessment of the process by which care is rendered in order to optimize billing, coding, and ultimately reimbursement is essential. Charge entry staff in each medical practice generate an insurance claim for a given medical provider by linking a diagnosis code with a procedure code and adding modifiers as needed. Claims are typically submitted to the insurance carrier electronically. The appropriateness of this coding translates into timely reimbursement to the provider. Each time a submission is rejected for any reason, the chance of that service ever being paid to the physician decreases significantly. Therefore, the ultimate goal is to generate a claim that is without error and medically appropriate and correctly describes the intervention. This chapter provides an overview of coding and billing for hemodialysis access procedures in the United States and should be used only as a guideline for the physician and coder since each insurance payer has their own rules and regulations.

Hemodialysis access recirculation decreases the adequacy of dialysis delivery to the patient and is important to diagnose because inadequate dialysis can be associated with increased mortality. In some series, a high degree of access recirculation can reliably predict a hemodynamically significant stenosis. Causes of recirculation include decreased arterial inflow (arterial anastomosis stenosis), decreased venous outflow (venous stenosis), and technical issues such as improper needle placement. This chapter discusses the different aspects in understanding hemodialysis access recirculation and management of complications associated with the above.

End Stage Renal Disease (ESRD) is a devastating disease affecting the health of many people world-wide. The primary goal of therapy for patients with ESRD is to maintain health throughout their life. The most effective therapy for ESRD is renal transplantation. Alternatively there are two modes of renal replacement therapy (RRT), peritoneal and hemodialysis. Peritoneal dialysis can be an excellent option for patients who have not undergone major abdominal operations, but does require wherewithal to perform peritoneal dialysis nightly. In North America many vascular surgeons do not perform placement of peritoneal dialysis catheters and as such this chapter will focus on hemodialysis.