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Medical errors can be defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Beyond their economic cost and their cost in human lives, errors cause loss of trust in the healthcare system by patients and diminished satisfaction by both patients and health professionals. There are many evidence-based safety-oriented behaviours and interventions that are easily implemented, such as ultrasound-guided central venous catheter insertion, prevention of catheter-related bloodstream infection and more. In vascular access, the development of research in patient safety has raised a variety of issues requiring study in order to provide the optimal patient safety approach. Patients are major contributors to their own safety, and as such, physicians should develop a new approach to involve them in the cycle of decision making through every step of their treatment. There are many opportunities along this path for the patient to be engaged in safety behaviours and for the access team to ensure such behaviours by employing simple strategies. The advent of the access centre, based on multidisciplinary teamwork, has enhanced the potential to improve patient safety by prevention of errors in planning and performing access surgery, avoiding delay in treatment of access malfunction and improving communication between the team members. However, a significant effort in research is still needed in order to implement intervention by evidence-based data focused on patient safety.

Purpose: In the Netherlands, 86% of patients start renal replacement therapy with chronic intermittent hemodialysis (HD). Guidelines do indicate predialysis care and maintenance of a well-functioning vascular access (VA) as critical issues in the management of the renal failure patient. Referral to the surgeon and time to VA creation are important determinants of the type and success of the VA and HD treatment., Methods and Results: Data from a national questionnaire showed that time from referral to the surgeon and actual access creation is <4 weeks in 43%, 4 to 8 weeks in 30% and >8 weeks in 27% of the centers. Preoperative ultrasonography and postoperative access flowmetry are the diagnostic methods in the majority of centers (98%). Most facilities perform rope-ladder cannulation with occasionally the buttonhole technique for selected patients in 87% of the dialysis units. Endovascular intervention for thrombosis is practiced by 13%, surgical thrombectomy by 21% and either endovascular or surgery by 66% of the centers. Weekly multidisciplinary meetings are organized in 57% of the units. Central vein catheters are inserted by radiologists (36%), nephrologists and surgeons (32%)., Conclusions: We conclude that guidelines implementation has been successful in particular regarding issues as preoperative patient assessment for VA creation and postoperative surveillance in combination with (preemptive) endovascular intervention, leading to very acceptable VA thrombosis rates.

Background: The Hemodialysis Reliable Outflow (HeRO) vascular access device is a hybrid polytetrafluoroethylene graft-stent construct designed to address central venous occlusive disease. Although initial experience has demonstrated excellent mid-term patency rates, subsequent studies have led to external validity questions. The purpose of this study was to examine a single center experience with this vascular access device in challenging access cases with associated costs., Methods: A retrospective study representing the authors' cumulative HeRO vascular access device experience was undertaken. The primary endpoint was graft failure or death, with secondary endpoints including secondary intervention rates and cost., Results: Forty-one patients with 15,579 HeRO days and a mean of 12.7 ± 1.5 mo with the vascular access device were available for analysis. Secondary patency was 81.6% at 6 mo and 53.7% at 12 mo. The reintervention rate was 2.84 procedures per HeRO vascular access device year. Associated HeRO costs related to subsequent procedures were estimated at $34,713.63 per patient/y., Conclusions: These data on the patency and primary outcome data diverge significantly from initial multicenter studies and represent a real-world application of this technology. It is costly to maintain patency. Use of HeRO vascular access devices should be judicious with outcome expectations reduced., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background and Objectives: Permanent hemodialysis vascular access is crucial for RRT in ESRD patients and patients with failed renal transplants, because central venous catheters are associated with greater risk of infection and mortality than arteriovenous fistulae or arteriovenous grafts. The objective of this study was to determine the types of vascular access used by patients initiating hemodialysis after a failed renal transplant., Design, Setting, Participants, & Measurements: Data from the US Renal Data System database on 16,728 patients with a failed renal transplant and 509,643 patients with native kidney failure who initiated dialysis between January 1, 2006, and September 30, 2011 were examined., Results: At initiation of dialysis, of patients with a failed transplant, 27.7% (n=4636) used an arteriovenous fistula, 6.9% (n=1146) used an arteriovenous graft, and 65.4% (n=10,946) used a central venous catheter. Conversely, 80.8% (n=411,997) of patients with native kidney failure initiated dialysis with a central venous catheter (P<0.001). Among patients with a failed transplant, predictors of central venous catheter use included women (adjusted odds ratio, 1.75; 95% confidence interval, 1.63 to 1.87), lack of referral to a nephrologist (odds ratio, 2.00; 95% confidence interval, 1.72 to 2.33), diabetes (odds ratio, 1.14; 95% confidence interval, 1.06 to 1.22), peripheral vascular disease (odds ratio, 1.31; 95% confidence interval, 1.16 to 1.48), and being institutionalized (odds ratio, 1.53; 95% confidence interval, 1.23 to 1.89). Factors associated with lower odds of central venous catheter use included older age (odds ratio, 0.85 per 10 years; 95% confidence interval, 0.83 to 0.87), public insurance (odds ratio, 0.74; 95% confidence interval, 0.68 to 0.80), and current employment (odds ratio, 0.87; 95% confidence interval, 0.80 to 0.95)., Conclusions: Central venous catheters are used in nearly two thirds of failed renal transplant patients. These patients are usually followed closely by transplant physicians before developing ESRD after a failed transplant, but the relatively low prevalence of arteriovenous fistulae/arteriovenous grafts in this group at initiation of dialysis needs to be investigated more thoroughly., (Copyright © 2014 by the American Society of Nephrology.)

Introduction: The aims of this study was to evaluate maintenance hemodialysis population in a tertiary care hospital based dialysis unit for vascular access (VA) types, to compare native arteriovenous fistula (AVF) and arteriovenous graft (AVG) survival, and to assess risk factors for access failure., Materials and Methods: A total of 182 patients on maintenance hemodialysis were evaluated and followed up in terms of VA type and VA outcomes., Results: Among 103 prevalent patients, 15.5% initiated dialysis with AVF. At the time of the study, 67.9% of the prevalent patients had an AVF and 29.1% had AVG. Of 79 incident patients, 64% were followed up for more than 3 months by nephrologists before initiation of dialysis. Among these patients, 13.6% were initiated with AVF. There were 25 primary failures and 50 secondary failure episodes. Of the 50 secondary failures, 15 were AVF failures and 31 AVG failures. Vascular access survival was significantly superior with AVF as compared with AVG (P = .03). With longer dialysis periods, failure rates were higher. Follow-up with nephrologists prior to initiation of dialysis had a major influence on VA., Conclusions: Arteriovenous fistula is the best VA for maintenance hemodialysis. However, when the vasculature is not ideal for AVF, AVG should be constructed. A small percentage of our patients had fistula at initiation of dialysis. This is mainly due to late nephrology referrals and also due to reluctance of patients to undergo surgical access placement when they are relatively asymptomatic.

Vascular access (VA) is the lifeline for patients with end-stage renal disease on regular hemodialysis (HD). Tunneled catheters have been associated with increased risk of luminal thrombosis, infection, hospitalization, and high cost. Our aims were to follow the "Fistula First Initiative," avoid or reduce the rate of catheter insertion, improve the rate of arteriovenous fistula (AVF) use, and study the effect of increased AVF use on quality of dialysis and patient's outcome. A VA program has been established in collaboration with an enthusiastic and professional vascular surgery team to manage 358 patients who have been on regular HD treatment for a period ranging from 1 to 252 months. The mean ± standard deviation age of patients was 52 ± 15 years with 62% male patients. Over a period of 2 years, 408 procedures were performed. These include 293 AVFs and 56 arteriovenous grafts (AVGs). Other procedures include 39 permanent catheter insertions, 8 AVF aneurysmectomy, removal of 6 AVGs, embolectomy of 4 AVGs, excision of 1 AVG lymphocele, and ligation of 1 AVF. This program resulted in significant increase in AVF rate from 35% to 82%; reduction in catheter rate from 62% to 10.9%; infection rate down from 6.6% to 0.6%; VA clotting down from 5.1% to 1.0%; and increase in average blood flow rate from 214 ± 32 to 298 ± 37 mL/min (P < 0.01). These results have been associated with improved average single pool Kt/V from 0.88 ± 0.19 to 1.28 ± 0.2 (P < 0.01); increased hemoglobin from 9.2 ± 1.2 to 10.9 ± 0.9 g/dL (P < 0.01); improved serum albumin from 3.2 ± 0.5 to 3.7 ± 0.4 g/dL (P < 0.05); reduction in administered erythropoietin dose by 19%; and significant drop in hospitalization rate from 6.1% to 3.8%. These results confirm the great benefits of AVF on quality of HD and patient outcome, and clearly affirm that AVF should always be considered first., (© 2013 International Society for Hemodialysis.)

Background: Advantages of the arteriovenous fistula (AVF), including long patency and few complications, were ascertained more than 2 decades ago and may not apply to the contemporary dialysis population., Study Design: Systematic review and meta-analysis. Estimates were pooled using a random-effects model and sources of heterogeneity were explored using metaregression., Setting & Population: Patients treated with long-term hemodialysis using an AVF., Selection Criteria for Studies: English-language studies indexed in MEDLINE between 2000 and 2012 using prospectively collected data on 100 or more AVFs., Predictor: Age, AVF location, and study location., Outcomes: Outcomes of interest were primary AVF failure and primary and secondary patency at 1 and 2 years., Results: 7,011 citations were screened and 46 articles met eligibility criteria (62 unique cohorts; n = 12,383). The rate of primary failure was 23% (95% CI, 18%-28%; 37 cohorts; 7,393 AVFs). When primary failures were included, the primary patency rate was 60% (95% CI, 56%-64%; 13 studies; 21 cohorts; 4,111 AVFs) at 1 year and 51% (95% CI, 44%-58%; 7 studies; 12 cohorts; 2,694 AVFs) at 2 years. The secondary patency rate was 71% (95% CI, 64%-78%; 10 studies; 11 cohorts; 3,558 AVFs) at 1 year and 64% (95% CI, 56%-73%; 6 studies; 11 cohorts; 1,939 AVFs) at 2 years. In metaregression, there was a significant decrease in primary patency rate in studies that started recruitment in more recent years., Limitations: Low quality of studies, variable clinical settings, and variable definitions of primary AVF failure., Conclusions: In recent years, AVFs had a high rate of primary failure and low to moderate primary and secondary patency rates. Consideration of these outcomes is required when choosing a patient's preferred access type., (Copyright © 2014 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Vascular access guidelines recommend routine screening for the timely detection of stenosis using noninvasive methods, including clinical assessment (monitoring) and device-based surveillance relying on access blood flow (Qa) and static intra-access pressure (sVPR, static venous pressure ratio) measurements and duplex ultrasound (DU)., Methods: We reviewed the literature to see how monitoring compares with surveillance in terms of compliance with the World Health Organization's criteria for screening tests., Results: The fundamental element of monitoring, physical examination (PE), has a fair-to-good performance in detecting stenosis in both fistulas and grafts, similar to the Qa criteria recommended in the guidelines. In fistulas, the "or" combination of a positive PE with a Qa <900 mL/min or sVPR >0.5 is more sensitive in detecting stenosis (in up to 98% of cases), making it as good as DU. In grafts, PE performed significantly less well in diagnosing stenosis than sVPR or DU.In randomized controlled trials on fistulas, Qa surveillance enables a significant halving of the risk of thrombosis and access loss by comparison with monitoring alone when Qa criteria highly sensitive to stenosis are considered. In grafts, neither Qa nor DU nor sVPR is able to reduce thrombosis or access loss rates by comparison with monitoring alone., Conclusions: Our analysis indicates that regular monitoring should be the backbone of any vascular access stenosis screening program (possibly associated with Qa and sVPR surveillance for fistulas), and PE should be part of every teaching program for caregivers involved in hemodialysis.

Background: A large proportion of newly created arteriovenous fistulas cannot be used for dialysis because they fail to mature adequately to support the hemodialysis blood circuit. The Hemodialysis Fistula Maturation (HFM) Study was designed to elucidate clinical and biological factors associated with fistula maturation outcomes., Study Design: Multicenter prospective cohort study., Setting & Participants: Approximately 600 patients undergoing creation of a new hemodialysis fistula will be enrolled at 7 centers in the United States and followed up for as long as 4 years., Predictors: Clinical, anatomical, biological, and process-of-care attributes identified pre-, intra-, or postoperatively., Outcomes: The primary outcome is unassisted clinical maturation, defined as successful use of the fistula for dialysis for 4 weeks without maturation-enhancing procedures. Secondary outcomes include assisted clinical maturation, ultrasound-based anatomical maturation, fistula procedures, fistula abandonment, and central venous catheter use., Measurements: Preoperative ultrasound arterial and venous mapping, flow-mediated and nitroglycerin-mediated brachial artery dilation, arterial pulse wave velocity, and venous distensibility; intraoperative vein tissue collection for histopathologic and molecular analyses; postoperative ultrasounds at 1 day, 2 weeks, 6 weeks, and prior to fistula intervention and initial cannulation., Results: Assuming complete data, no covariate adjustment, and unassisted clinical maturation of 50%, there will be 80% power to detect ORs of 1.83 and 1.61 for dichotomous predictor variables with exposure prevalences of 20% and 50%, respectively., Limitations: Exclusion of 2-stage transposition fistulas limits generalizability. The requirement for study visits may result in a cohort that is healthier than the overall population of patients undergoing fistula creation., Conclusions: The HFM Study will be of sufficient size and scope to: (1) evaluate a broad range of mechanistic hypotheses, (2) identify clinical practices associated with maturation outcomes, (3) assess the predictive utility of early indicators of fistula outcome, and (4) establish targets for novel therapeutic interventions to improve fistula maturation., (Copyright © 2013 National Kidney Foundation, Inc. All rights reserved.)

Background: The number of older patients starting 
hemodialysis is continuously increasing. The type of vascular access plays an important role in dialysis treatment, but it can be difficult to create in older patients., Methods: This study compared vascular access survival rates and patient survival rates in older (≥65 years) and younger (<65 years) patients starting hemodialysis in 2 Italian hospitals in 2006-2008., Results: The study enrolled 336 patients: 208 ≥65 years and 128 <65 years of age. The vascular accesses used, in order of frequency, were 102 distal arteriovenous fistulas (dAVFs) (49%), 55 midarm AVFs (pAVFs) (26%), 9 arteriovenous grafts (AVGs) (4%) and 42 central venous catheters (CVCs) (20%) in the older patients, and 89 dAVFs (69%), 25 pAVFs (19%), 6 AVGs (5%) and 8 CVCs (6%) in the younger patients. Survival rates of fistula and catheter did not differ between the 2 groups. AVGs failed earlier (p = 0.02) in the older patients. On Cox analysis, age (hazard ratio [HR] = 1.073; p<0.001) and CVC (HR = 4.152; p<0.001) increased the risk of death., Conclusion: A fistula is the gold standard for hemodialysis vascular access in older patients if judged appropriately.

The American College of Cardiology Foundation (ACCF), in partnership with key specialty and subspecialty societies, conducted a review of common clinical scenarios where noninvasive vascular testing (venous ultrasound and physiological testing) is frequently considered. The indications (clinical scenarios) were derived from common applications or anticipated uses, as well as from current clinical practice guidelines and results of studies examining the implementation of the original appropriate use criteria (AUC). The 116 indications in this document were developed by a diverse writing group and scored by a separate independent technical panel on a scale of 1 to 9, to designate appropriate use (A) (median 7 to 9), maybe appropriate use (M) (median 4 to 6), and rarely appropriate use (R) (median 1 to 3).

Due to high nonmaturation rates, arteriovenous fistulas (AVF) frequently require intervention(s) to promote maturation. Endovascular or surgical interventions are often undertaken to salvage nonmaturing AVFs. The objective of this study was to compare the impact of surgical versus endovascular interventions to promote AVF maturation on cumulative AVF survival. We evaluated 89 patients with new AVF placement from a Veterans Affairs population over a 5-year period. Of these, 46 (52%) required intervention(s) to achieve successful maturation for dialysis: 31 patients had surgical revisions and 15 patients had endovascular repairs. We compared cumulative survival between AVFs requiring no intervention, surgical revision, and endovascular intervention to promote AVF maturation. Cumulative survival was longer in AVFs receiving surgical intervention compared with angioplasty to promote AVF maturation (p = 0.05). One-year cumulative survival was 86% vs. 83% vs. 40% for no intervention vs. surgery vs. angioplasty, respectively. In AVFs that required interventions to promote maturation, AVFs with surgical intervention had longer cumulative survival compared with those AVFs with endovascular intervention. AVFs with surgical intervention to promote maturation had similar 1-year cumulative survival to those AVFs that did not require intervention to promote maturation., (© 2012 Wiley Periodicals, Inc.)

The study was aimed at optimizing the policy of forming a permanent vascular access (PVA) by means of preoperative colour duplex scanning (CDS) of vessels in patients on programmed haemodialysis. The study included 420 patients undergoing from September 2003 to September 2011 a total of 595 PVAs. The Study Group (Group I) patients (351 PVAs) were subjected to preoperative PVA of vessels of limbs accompanied by assessing velocity parameters of the venous blood flow. The comparison group (Group II) patients (244 PVAs) underwent clinical examination only. The end point of the study was early diagnosis of incompetence of the PVA. Using preoperative PVA of vessels improved the outcomes of forming the PVA, significantly increasing the number of native arteriovenous fistulas (AVF) as a whole: (88.0% for Group I and 65.6% for Group II; p<0.01), their variants: radial-cephalic (I - 57.5%, II - 32.2%; p<0.01) and secondary radial-cephalic variants (I - 8.3%, II - 3.7%; p<0.01), leading to decreased frequency of using synthetic prostheses both totally (I - 12.0%, II - 34.4%; p<0.01) and in all positions (p<0.01) taken apart. Also decreased the frequency of the development of incompetence of all PVAs (I - 10.8%, II - 29.9%; p<0.01), AVFs as a whole (I - 7.4%, II - 18.0%; p<0.01) and accesses with a synthetic prosthesis both as a whole (I - 1.7%, II - 11.9%; p<0.01) and in all positions separately (p<0.01). Determining the velocity parameters of venous blood flow made it possible to exclude the development of significant proximal venous obstruction and to refuse phlebography. We consider it obligatory to perform CDS of vessels prior to forming a PVA.

Introduction: Dialysis access should be timely, minimise complications and maintain functionality. Good functional access is required for renal replacement therapy (RRT) to be successful. The aim of the combined vascular and peritoneal dialysis access audit was to examine practice patterns with respect to dialysis access and highlight variations in practice between renal centres., Methods: The UK Renal Registry collected centre-specific information on vascular and peritoneal access outcome measures including patient demographics, dialysis access type (at start of dialysis and three months after start of dialysis), surgical assessment and access functionality. The combined access audit covered incident haemodialysis (HD) and peritoneal dialysis (PD) patients in 2012 from England, Northern Ireland and Wales. Centres who had reported data on incident PD patients for the previous audit in 2011 were additionally asked to provide one year follow up data for this group., Results: Fifty-one centres in England, Wales and Northern Ireland (representing 82% of all centres) returned data on first access from 3,720 incident HD patients and 1,018 incident PD patients. A strong relationship was seen between surgical assessment and the likelihood of starting HD with an arteriovenous fistula (AVF). Type of first access was related to the length of time known to renal services with higher numbers of AVFs and PD catheters used in patients known to renal services for at least one year. Three month and one year outcomes of HD and PD access were poorly reported., Conclusions: This audit provides information on important patient related outcome measures with the potential to lead to an improvement in access provision. This represents an important advance, however data collection remains suboptimal. There is wide practice variation across the England, Wales and Northern Ireland in provision of both HD and PD access which requires further exploration., (© 2014 S. Karger AG, Basel.)

Purpose: There is limited literature available to guide physicians on a course of action when they are approached by renal transplant recipients regarding the status of their vascular accesses. However, this is a frequent topic of discussion with these patients and there should be guidelines available to assist in the decision of whether to maintain or ligate an arteriovenous fistula (AVF) in a successful renal transplant patient. This review intends to present some of the literature, as well as to establish guidelines for management., Methods: The medical literature was reviewed and anecdotal information from our clinical experience was collected., Results: Taking into account 10-year adjusted renal transplant graft survival rates, and the relative paucity of donors, it is possible that a successfully transplanted patient will have to return to dialysis at some point. After review of the literature, the impact of AVF ligation on the transplant patient's cardiac morphology and function is not clear. Patient and graft survival do not appear to be impacted by persistent AVFs. Emergent closure of the AVF might be required in cases of severe venous hypertension, risk of rupture from pseudoaneurysm, significant high output cardiac failure or ischemic hand., Conclusions: We recommend that following successful renal transplantation, functioning AVFs should almost never be ligated. Many patients require return to dialysis and the physiologic impact of the patent AVF on these patients does not strongly advocate routine ligation following transplant.

Background: Obtaining vascular access suitable for long-term use in hemodialysis patients is of utmost importance. In these patients, autogenous methods are generally used for access. There are various techniques for obtaining autogenous access in hemodialysis patients., Material/methods: Our objective was to evaluate the outcomes of the "diamond-shaped anastomosis" technique used as a surgical technique during the creation of arteriovenous fistulas in patients with chronic renal failure. We randomly selected and retrospectively examined 67 patients on whom the "diamond-shaped anastomosis" technique had been performed., Results: We found an 89% patency rate in the 67 randomly selected patients on whom we applied this technique in the early stage (first 6 months)., Conclusions: Maintaining fistula patency in the early postoperative period is important in fistula functioning. The diamond-shaped anastomosis is a simple technique with proven efficiency. This method can be applied in all situations and contributes to postoperative early stage latency.

Introduction: In Italy, the use of arteriovenous grafts (AVG) is limited (1-5 %) due to different approaches to vascular access (VA) management as compared to other countries, where guidelines (which may not apply to the Italian setting) have been produced. Therefore, the Study Group (GdS) on VA of the Italian Society of Nephrology produced this position paper, providing a list of 8 recommendations built upon current guidelines., Methods: The most controversial and innovative issues of existing guidelines have been summed up in 12 different statements. We selected 60 Italian dialysis graft experts, nephrologists and vascular surgeons (PP1SIN Study Investigators). They were asked to express their agreement/disagreement on each issue, thus creating a new method to share and exchange information., Results: Most of them agreed (consensus > 90%) on specific criteria set to choose AVG over native AVF (nAVF) and tunnelled venous catheter (tVC) and on the necessary conditions to implant them. They did not fully agree on the use of AVG in obese patients, in patients at risk of developing ischemia, on the priority of AVG as an alternative to brachial-basilic fistula with vein transposition, and in case of a poorly organized setting regarding graft maintenance. Keeping in mind that the nAVF should be preferred whenever is feasible, AVGs are indicated when superficial veins are unavailable or to repair a nAVF (bridge graft). An AVG is an alternative to tVC if the expected patient survival is long enough to guarantee its clinical benefits.

An arteriovenous fistula (AVF) is the optimal vascular access for hemodialysis (HD), because it is associated with prolonged survival, fewer infections, lower hospitalization rates, and reduced costs. The AVF First breakthrough initiative (FFBI) has made dramatic progress, effectively promoting the increase in the national AVF prevalence since the program's inception from 32% in May 2003 to nearly 60% in 2011. Central venous catheter (CVC) use has stabilized and recently decreased slightly for prevalent patients (treated more than 90 days), while CVC usage in the first 90 days remains unacceptably high at nearly 80%. This high prevalence of CVC utilization suggests important specific improvement goals for FFBI. In addition to the current 66% AVF goal, the initiative should include specific CVC usage target(s), based on the KDOQI goal of less than 10% in patients undergoing HD for more than 90 days, and a substantially improved initial target from the current CVC proportion. These specific CVC targets would be disseminated through the ESRD networks to individual dialysis facilities, further emphasizing CVC avoidance in the transition from advanced CKD to chronic kidney failure, while continuing to decrease CVC by prompt conversion of CVC-based hemodialysis patients to permanent vascular access, utilizing an AVF whenever feasible., (© 2012 Wiley Periodicals, Inc.)

Purpose: The aim of the study was to ascertain whether a Cimino First policy can be implemented successfully in tertiary practice using a standardized technique., Methods: This is a retrospective study. All first radial-cephalic (Cimino) fistulas placed by a single surgeon in incident patients were studied. A standardized surgical technique was used paying attention to the dorsal cephalic branch. No balloon maturation or early surveillance was performed. Kaplan-Meier survival analysis using survfit function in R (Vienna) was applied., Results: Fifty-seven (69%) of 83 new accesses were radial cephalic fistulas. Of these, 44 (77.2%) were men. The patients were aged 17 to 83 (mean 54.1; SD 14.6) years. Whites comprised of 21 (36.8%), maori 18 (31.6%), and pacific islanders 16 (28.1%). Comorbidities included diabetes in 32 (56.1%), hypertension in 47 (82.5%), and hyperlipidemia in 25 (46.3%; n=54). Twenty-six (45.6%) were pre-dialysis. Mean body mass index was 30.74 (SD 6.9) Kg/m² (n=56). Mean vein diameter was 3.3 mm (range 2.1-6.2 mm; n=36). Twenty-six (45.6%) had had previous central lines. Forty-four (77.2%) fistulas matured. Mean maturation time was 14.0 weeks. Thirty-six (63.2%) were used for dialysis while eight patients remained pre-dialysis with patent fistulas. Primary patency at one year and 18 months was 69.2% and 57.4% respectively. The figures for assisted primary patency were 85.6% and 72.3% respectively. Secondary patency was 87.6% and 83.9% at one and two years., Conclusions: Cimino fistulas can be performed in a majority of patients with good results using a standardized surgical technique. The importance of the dorsal cephalic branch needs to be studied.

In November 2010, Northwest Renal Network was the first of the 18 ESRD Networks to reach the Fistula First goal of greater than 66% prevalent hemodialysis patients using an arteriovenous fistula (AVF). The network has sustained that goal over time and as of August 2011, has achieved an AVF rate of 67.7%. The Northwest Renal Network has been successfully motivating facilities to embrace change using thorough root cause analyses and targeted quality improvement projects throughout the Network's five-state region.

For the last 40 years, most of the research and publications on hemodialysis access, has focused on the management of its complications e.g. thrombosis, infection, aneurysms. In other words, a damage control strategy. While this is undoubtedly an important part of access management, it is a deficient reactive strategy that does not enhance a better quality of life for patients or help reduce the burden on health care resources. To achieve these objectives, efforts should be directed at ways which provide a longer access life with fewer complications. Such an approach would save costs and reduce the suffering of the patient. In this paper we will focus on hemodialysis management in Saudi Arabia, describe the reasons for the current unsatisfactory situation, and highlight possible remedies.

Background: For chronic hemodialysis, the ideal permanent vascular access is the arteriovenous fistula (AVF). Temporary catheters should be reserved for acute dialysis needs. The AVF is associated with lower infection rates, better clinical results, and a higher quality of life and survival when compared to temporary catheters. In Brazil, the proportion of patients with temporary catheters for more than 3 months from the beginning of therapy is used as an evaluation of the quality of renal units. The aim of this study is to evaluate factors associated with the time between the beginning of hemodialysis with temporary catheters and the placement of the first arteriovenous fistula in Brazil., Methods: This is an observational, prospective non-concurrent study using national administrative registries of all patients financed by the public health system who began renal replacement therapy (RRT) between 2000 and 2004 in Brazil. Incident patients were eligible who had hemodialysis for the first time. Patients were excluded who: had hemodialysis reportedly started after the date of death (inconsistent database); were younger than 18 years old; had HIV; had no record of the first dialysis unit; and were dialyzed in units with less than twenty patients. To evaluate individual and renal unit factors associated with the event of interest, the frailty model was used (N = 55,589)., Results: Among the 23,824 patients (42.9%) who underwent fistula placement in the period of the study, 18.2% maintained the temporary catheter for more than three months until the fistula creation. The analysis identified five statistically significant factors associated with longer time until first fistula: higher age (Hazard-risk - HR 0.99, 95% CI 0.99-1.00); having hypertension and cardiovascular diseases (HR 0.94, 95% CI 0.9-0.98) as the cause of chronic renal disease; residing in capitals cities (HR 0.92, 95% CI 0.9-0.95) and certain regions in Brazil - South (HR 0.83, 95% CI 0.8-0.87), Midwest (HR 0.88, 95% CI 0.83-0.94), Northeast (HR 0.91, 95% CI 0.88-0.94), or North (HR 0.88, 95% CI 0.83-0.94) and the type of renal unit (public or private)., Conclusion: Monitoring the provision of arteriovenous fistulas in renal units could improve the care given to patients with end stage renal disease.

Background: The use of arteriovenous fistulas (AVFs) among hemodialysis (HD) patients has been consistently associated with lower rates of morbidity and mortality; however, up to 30% of eligible patients refuse the creation or cannulation of an AVF. We aimed to understand the attitudes, beliefs, preferences and values of patients who refused creation or use of an AVF., Methods: With qualitative methodology, we conducted semi-structured interviews with 13 HD patients (Canada, 2009), who previously refused creation or use of an AVF. Three independent analysts reviewed interview transcripts., Results: We discovered three main themes that impacted the decision to refuse a fistula: (i) poor previous personal or vicarious experiences with the fistula, including cannulation, bleeding, time commitment and appearance; (ii) knowledge transfer and informed decision making. Patients identified information from other patients to be as important as information from health care workers, that information on vascular access (VA) was presented but not understood and that timing of information was crucial with information overload at the start of dialysis and (iii) maintenance of status quo and outlook on life. Some patients stated they live day-to-day without being influenced by the mortality risks with a catheter., Conclusions: AVF refusal is multifactorial and depends on individual patients. Although nephrologists consider the fistula to be the optimal VA, patients do not think in the same terms of reducing infection rates but focus on the practical day-to-day use of their VA and its influence on their quality of life and future outlook.

The emphasis on increasing the use of autogenous hemodialysis access in the United States has clearly changed the practice pattern of vascular surgeons during the past decade. However, this change has also been associated with an increased use of cuffed dialysis catheter and a decrease in the autogenous access maturation rate. Future efforts to increase autogenous access use will be hampered, in part, by the characteristics and comorbidities of the aging hemodialysis population and system-wide health care delivery issues, such as late referral for vascular access. As a result, prosthetic access will continue to play an important role in providing vascular access for the US hemodialysis population. This article reviews contemporary trends and evidence-based literature related to autogenous and prosthetic access procedures, as well as factors that influence access choice., (Copyright © 2011 Elsevier Inc. All rights reserved.)

This paper presents an overview of the project carried out by the Vascular Access (VA) Working Group of the Italian Society of Nephrology with the aim of developing 4 position papers at the national level on how to choose, use, and implant the different, possible types of vascular access. The topics of the project are: 1) recommendations on the use of prosthetic arteriovenous fistulas for vascular access in hemodialysis, 2) recommendations on the use of venous catheters for hemodialysis, 3) infections induced by a venous catheter for hemodialysis, and 4) how to create and maintain a vascular access for hemodialysis. This paper also gives an explanation of the difficulties existing in Italy in the implementation of international guidelines, mostly due to significant differences in the procedures for the creation of VA, compared with the countries where most of the literature on the subject has been published. Individual position papers were drafted for each of the different topics. A list of recommendations was produced based on existing guidelines. Then these recommendations were critically reviewed by experts working in Italy, who expressed their opinion on their inclusion in position papers. The working method used to gather the opinions of the various experts is described. The final target is to provide clinicians interested in VA with updated documents on selected topics. Such documents will be updated periodically, and they will present a thorough overview of expert opinions.

The Fistula First Breakthrough Initiative (FFBI) has improved the awareness of the value of fistula creation in patients with end-stage renal disease (ESRD). The FFBI Health Policy Workgroup has been charged with reviewing the relationship of policy and economic issues to this project. This article reviews the efforts and successes of renal community clinical activities and reemphasizes the economic impact of fistula creation and catheter reduction on the health care system. Major obstacles are discussed, and existing tools and efforts designed to address them are outlined. The FFBI Health Policy Workgroup then identifies less frequently recognized barriers to the achievement of the FFBI goals and suggests solutions to them. It concludes that nephrologists need to assume the leadership role and drive fistula creation and central venous catheter reduction to achieve programmatic success., (© 2011 Wiley Periodicals, Inc.)

Arteriovenous fistula (AVF) surveillance is pivotal to early detection of stenosis, in order to avoid subsequent thrombosis. Access flow measurement is the method recommended by the available guidelines. With respect to grafts, in native AVF the best thresholds of access flow intervention, optimal timing of monitoring and cost-effectiveness are still debated. In fact, monthly measurement of access flow is difficult to obtain in most modern hemodialysis units. Moreover, in native AVF it is not always possible to perform the gold-standard surveillance methods. Finally, clinical evaluation is not enough to identify the small number of patients at risk of stenosis. The QB stress test (QBST) is a new and simple screening test that was created to identify inflow stenosis and thereby malfunctioning AVF. QBST shows a good correlation with access flow measurements obtained by the ultrasound dilution technique. Moreover, the test can be performed in every type of native AVF. Patients with a positive QBST result had a lower access flow than patients with a negative QBST result (433+-203 vs 1168+-681 mL/min, p<0.0001). The positive predictive value for inflow stenosis was 76.3%. During a 22-month followup, we were able to achieve a low thrombosis rate (1.5 instances of thrombosis per 100 patient-years). In conclusion, adding QBST to the clinical evaluation could offer a new solution for the long-standing AVF surveillance problem.

The population of patients with ESRD in the United States is progressively increasing, with hemodialysis (HD) as the major mode of renal replacement therapy. The National Kidney Foundation's Dialysis Outcomes and Quality Initiative and the Fistula First Initiative recommend increasing the use of arteriovenous fistulae (AVF) in both incident and prevalent hemodialysis patients. One measure proposed is the use of pre-operative vascular mapping to assess the upper extremities for the presence of suitable vessels prior to the surgical creation of an AVF among both pre-dialysis CKD and ESRD patients on HD. This article aims to review the literature on vascular mapping, including the various techniques; their advantages and disadvantages; and whether they help to maximize the AVF creation rate as well as increase the use of AVF in the HD population.

We tested a new bedside method to determine the function of native arteriovenous fistula in 16 patients performed during hemodialysis without stopping the treatment. We initially measured vascular access flow (Q(a)) in each patient using the Transonic HD01(plus) device. We then measured the pressure in arterial and venous drip chambers at different blood pump flow rates (Q(bset)=0, 50, 100, 250, 300, 350 ml/min). The intravascular blood pressure gradient (P(f)) between arterial and venous puncture sites was estimated by a mathematical model. P(f) was positive for low Q(bset), but became negative when Q(bset) overcame the threshold value (Q(Inv)). Such critical flow showed a high correlation with Q(a), even if it was systemically lower. Computer analysis of fluid dynamics showed that when the blood pump flow overcame the Q(Inv) threshold, a critical transition from laminar flow to vortex circulation took place downstream of the venous needle, causing a dangerous shearstress on the vessel wall. Our results show that Q(Inv) provides an indication of the maximal blood pump flow rate needed to be reached to maximize blood flow supply in order to limit hemodynamic stress on the vascular access.

Vascular access has been a major problem in the management of end stage renal disease (ESRD) patients on chronic hemodialysis (HD). Native arteriovenous fistulas (AVFs) are the preferred vascular access for ESRD patients on HD. Multiple factors have been evaluated as causes for poor AVF rates. The purpose of this retrospective analysis was to assess the impact of training of nephrologist in interventional nephrology (IN) on vascular access outcomes. We studied the rates of different types of vascular access amongst patients on chronic HD under the care of two nephrology groups over 25 months in a community dialysis unit. In group A, all vascular access were managed directly by an interventional nephrologist, while in group B they were managed by general nephrologist with no exposure to IN during their training. A total of 129 patients received dialysis for at least 4 months at the unit during those 25 months. The rate of AVFs in group A was 56.6%, while in group B the rate of AVFs was 40.8% (p = 0.059). The rate of AVGs in group A was 22.9% and in group B it was 27.6% (p = 0.647). The tunneled HD catheter rate in group A was 20.4% and in group B it was 31.6% (p = 0.098). The results of this study demonstrate that training of nephrologists in IN leads to increased use of AVF as HD vascular access. We suggest that training programs in nephrology should consider incorporating IN into their programs to increase the prevalence of AVFs.

The Society for Vascular Surgery considers the placement and maintenance of arteriovenous hemodialysis access to be an important component of any vascular surgery practice. Therefore, the Society has long been involved in setting the standards for the management of arteriovenous access. Formulating clinical recommendations in this area is the latest effort by the Society to improve the management of arteriovenous access on a national level. To provide an unbiased study of the evidence and to help in formulating the recommendations, the Society used the Knowledge and Encounter Research (KER) Unit of the Mayo Clinic College of Medicine, Rochester, Minn, to review the available evidence and advise a multidisciplinary group of access surgeons and nephrologists in formulating the clinical recommendations. To review the evidence, randomized and observational study designs were both considered. Whenever possible, systematic reviews and meta-analyses of the literature were used because, compared with individual studies, they generate more precise estimates of treatment effects and their results are applicable to a wider range of patients. On behalf of the Society, the group issued its recommendations following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) format; this format disentangles the strength of recommendations from the quality of the evidence and encourages statements about the underlying values and preferences relevant to the particular recommendation. The recommendations are classified as strong (denoted by the phrase "we recommend") or weak (denoted by the phrase "we suggest"); and the quality of evidence is classified as high, moderate, low, or very low. These recommendations are not meant to supersede clinical judgment; rather, they should be used as a guide for the practicing surgeon and nephrologist as the decision is being made for the placement and subsequent procedures and management of arteriovenous hemodialysis access are being considered.

Peritoneal dialysis (PD) is a well-established renal replacement therapy for end-stage renal disease patients. Nonetheless, on an annual basis, at least 10% of patients shift from PD to hemodialysis for a variety of reasons. Thus the issue of vascular access creation needs to be addressed for this small but significant group of patients. Despite the relatively consistent number of dropouts, the creation of an arteriovenous fistula prior to transfer remains suboptimal, and variable from center to center. Literature for this specific area is poor and dated. Guidelines seem to suggest vascular access creation in high-risk failure patients, but they have no detailed criteria to select patients that would likely fail PD and therefore take advantage of a backup access. There is a need to better understand and predict patients that require conversion to hemodialysis to develop a plan that focuses on wellness and maximum quality of life in the lifecycle of PD patients. This review addresses the issue of vascular access planning in adult PD patients, presents the available literature on the topic and the current guidelines and recommendations, and describes a research agenda to guide decision making in clinical practice.

Recognizing the impact of the decision making by the dialysis access surgeon on the successful placement of autogenous arteriovenous hemodialysis access, the Society for Vascular Surgery assembled a multispecialty panel to develop practice guidelines in arteriovenous access placement and maintenance with the aim of maximizing the percentage and functionality of autogenous arteriovenous accesses that are placed. The Society commissioned the Knowledge and Encounter Research Unit of the Mayo Clinic College of Medicine, Rochester, Minnesota, to systematically review the available evidence in three main areas provided by the panel: timing of referral to access surgeons, type of access placed, and effectiveness of surveillance. The panel then formulated practice guidelines in seven areas: timing of referral to the access surgeon, operative strategies to maximize the placement of autogenous arteriovenous accesses, first choice for the autogenous access, choice of arteriovenous access when a patient is not a suitable candidate for a forearm autogenous access, the role of monitoring and surveillance in arteriovenous access management, conversion of a prosthetic arteriovenous access to a secondary autogenous arteriovenous access, and management of the nonfunctional or failed arteriovenous access. For each of the guidelines, the panel stated the recommendation or suggestion, discussed the evidence or opinion upon which the recommendation or suggestion was made, detailed the values and preferences that influenced the group's decision in formulating the relevant guideline, and discussed technical remarks related to the particular guideline. In addition, detailed information is provided on various configurations of autogenous and prosthetic accesses and technical tips related to their placement.

Vascular access cannulation for dialysis staff is the most difficult obstacle to overcome during the orientation process and can remain a challenge throughout one's career in caring for patients with renal disease. Learning the "buttonhole technique" can make venipuncture more comfortable for the patient and can eliminate the fear of failure for the cannulator. Not only does it preserve the timeframe of the patient's access, but establishes a routine process for the dialysis facility to follow for successful cannulation.

Background: In 2002, the Center for Medicare and Medicaid Services (CMS) required all 18 Renal Networks to participate in a Vascular Access Quality Improvement Program (QIP). The Northwest Renal Network (NWRN 16) chose to increase arteriovenous fistula (AVF) use. NWRN 16 hypothesized that strategies which targeted the improvement of AVF rate and the reduction of catheter use were the same. In December 2001, 44.2% of hemodialysis (HD) patients in the NWRN 16 received HD using an AVF which met the Dialysis Outcome Quality Initiative (K/DOQI) 40% AVF guideline for prevalent patients. However, 43% of HD facilities (2869 patients) had less than 40% of AVF and higher HD catheter rates than the average Network catheter rates (25.0 vs. 20.3%). To address the needs of underperforming facilities, NWRN 16 provided education and tools for their vascular access decision makers to promote AVF creation and catheter reduction., Methods: In 2002, NWRN 16 sponsored four regional workshops targeted at nephrologists, vascular surgeons, HD nurses, and interventional radiologists., Results: Percentage of AVFs in use in invited facilities increased from 31.3% pre-intervention to 56.2% at 4 yrs: 78% increase (99% confidence interval: 77.8% to 81.5%). Percentage of catheters increased from 25% to 25.8%: 3.2% change over 4 yrs (99% confidence interval: 2.5% to 4%)., Conclusion: The success of Network 16's AVF interventions demonstrates the effectiveness of Network education promoting multidisciplinary teamwork, and innovative strategies to increase dramatically AVF use without substantial increase in catheter use.

The National Kidney Foundation Dialysis Outcomes and Quality Initiative (DOQI) recommends autogenous fistulae as the preferred access for new dialysis procedures. Unfortunately, despite superior patency rates compared to prosthetic grafts, even autogenous access durability is often undermined by venous stenosis due to intimal hyperplasia at the outflow vein or by central venous stenosis due to long-standing central venous catheters. Salvage interventions, in the form of endovascular treatments such as percutaneous transluminal angioplasty (PTA) and/or stenting, are increasingly utilized for access salvage and maintenance. The objective of this study was to evaluate the efficacy of endovascular dialysis interventions in the era of DOQI. A retrospective review of a database of endovascular interventions for dialysis access during 36 months at an academic medical center was performed. Both central venous and access outflow lesions were included in the analysis. Kaplan-Meier curves and log-rank analysis were used to assess and compare time-dependent variables. Forty-five patients with dialysis access underwent 72 endovascular interventions for access maintenance. There were 27 central venous and 32 outflow endovascular interventions with 98% follow-up. Primary and assisted primary patency rates for outflow balloon PTA were 50% and 72% at 12 months, respectively. There were 1.1 reinterventions required per index outflow PTA procedure. Postintervention primary patency rates for central venous PTA were 30% and 9% at 6 and 12 months, respectively. Postintervention assisted patency for central venous PTA was 100% at 12 months, requiring 1.8 reinterventions per index PTA. Central venous and venous outflow interventions extended overall access patency by 38.5 and 33 months, respectively (p < 0.0001). Endovascular interventions are the mainstay of treatment for the malfunctioning dialysis access. Despite the need for multiple reinterventions and close surveillance, catheter-based interventions positively contribute to dialysis access durability in accordance with DOQI guidelines.

An increasing number of renal dialysis-dependent patients with Arterio-Venous fistulae are undergoing cardiac surgery.The fistula has important effects on systemic hemodynamics in dialysis patients. The flow is significantly and positively related to cardiac output and cardiac index, and inversely related to pulmonary vascular resistance.Few problems are encountered on cardiopulmonary bypass despite left to right shunting of blood. We present an unusual case in which a large brachial Arterio-Venous fistula with large collaterals prevented weaning off cardiopulmonary bypass.

According to the "Fistula First Initiative" surgeon selection should be based on best outcomes, willingness, and ability to provide access services. This analysis presents arteriovenous access placement and outcomes in 75 patients when surgery was performed by one of two dedicated high-volume vascular access surgeons (community [surgeon I] and academic medical center [surgeon II]). Preoperative vascular mapping was performed in all the patients. Demographic characteristics were similar except that patients referred to surgeon I (n = 40) were older (52.7 +/- 16.2 years vs. 45.4 +/- 13.7 years; p = 0.04) and tended to have more previously failed accesses (50% vs. 29%; p = 0.06) and black race (65% vs. 43%; p = 0.055) including a history of previously failed accesses (50% for surgeon I and 29% for surgeon II; p = 0.06). Similarly, there was no significant difference in the size of forearm ([surgeon I: 2.0 +/- 1.0 mm], [surgeon II: 1.9 +/- 0.8 mm]; p = 0.45) or upper arm veins (cephalic vein: surgeon I = 3.2 +/- 1.4 mm, surgeon II = 2.9 +/- 1.2 mm, p = 0.34; basilic vein: surgeon I = 5.0 +/- 1.2 mm, surgeon II = 4.7 +/- 1.3 mm, p = 0.25). Fistulae placement occurred in 98% vs. 71% (p = 0.001) for surgeon I and II, respectively. Characteristics predictive of fistula placement over an arteriovenous graft were surgeon selection (odds ratio [OR] = 19.52; p = 0.01) and no history of diabetes (OR = 7.61; p = 0.016). Kaplan-Meier analysis revealed 6 and 12 months overall access survival rates of 82%, 58% and 82% and 47% for surgeon I and II, respectively (p = 0.007). This analysis demonstrates that surgeon selection can have a significant impact on the rate of fistula placement and its overall survival despite similar findings on preoperative vascular mapping.

Objective: To study whether surgical trainees can perform arteriovenous fistula (AVF) surgery to a standard comparable to consultants., Patients and Methods: Retrospective study of all vascular access surgery over a three year period at a single centre. The operating surgeon was identified from theatre log books and categorised by grade. Fistula patency was used as the primary outcome measure and was determined from patients' case-notes and from a prospectively collected electronic record of dialysis sessions. Patency was defined as "used for dialysis" if the AVF was used for dialysis for at least 6 consecutive sessions., Results: One hundred and eighty six cases were used for analysis. In 60 cases (32%) the operating surgeon was the consultant, in 53 cases (29%) a trainee was supervised by a consultant, in 56 cases (30%) a trainee performed the operation independently and in 17 cases (9%) the grade of the operating surgeon could not be established. Primary and primary assisted patency rates by operating surgeon did not differ significantly (P-values 0.25 and 0.16 respectively). Age of the patient was the only predictor of patency failure in a multivariate model. Grade of operating surgeon (logrank test chi(2)=3.1, p=0.38) and type of fistula (logrank test chi(2)=2.3, p=0.52) were not significantly related to the primary survival of the fistula., Conclusions: This study showed no significant differences in AVF patency rates between trainee and consultant surgeons. Allocation of appropriate cases can result in trainees obtaining similar outcomes as consultants, demonstrating that dialysis access surgery can provide good training opportunities for junior doctors without detriment to patient care.

Background and Objectives: Vascular access standards are predominantly based on older, single-center reports; however, the hemodialysis population has changed dramatically and primary arteriovenous fistula failure is a huge problem. This prospective, multicenter study used standardized definitions to analyze patency rates and potential risk factors that affect functional patency and late arteriovenous fistula functionality., Design, Setting, Participants, & Measurements: Eleven centers participated in a guidelines implementation program. All new permanent vascular accesses were included. Patency and functional patency, defined as access survival from creation and from first dialysis use, respectively, were calculated using Kaplan-Meier analysis. Risk factors for primary functional patency loss (intervention-free interval) and secondary failure (abandonment) were determined using regression models., Results: A total of 491 arteriovenous fistulas were placed in 395 patients. Six-, 12-, and 18-mo secondary patency and functional patency were 75 +/- 2.0, 70 +/- 2.3, and 67 +/- 2.7% and 90 +/- 1.9, 88 +/- 2.2, and 86 +/- 2.7%, respectively. Primary failure rate was 40%. Thrombosis rate was 0.14 per patient-year. Diabetes and arteriovenous fistula surveillance were significantly associated with primary functional patency loss. Preoperative duplex was inversely related to secondary failure. The secondary failure rate per hospital varied from 0 to 39%., Conclusions: This study showed a marked difference between patency and functional patency, likely to be explained by high primary failure rates. Hemodialysis patients with diabetes can be expected to have reduced primary functional patency rates, but if treated adequately, then arteriovenous fistula functionality can be maintained as long as in patients without diabetes.

Background: DOQI (The Dialysis Outcomes Quality Initiative) recommend 40% of prevalent renal failure patients should be undergoing hemodialysis (HD) using autogenous arteriovenous fistulae (AVF). The aim of this study is to assess the primary patency rates of wrist and elbow fistulae, and to examine how patient variables influence the success of a fistula. In addition, an attempt has been made to address the main issue of survival rates in this high risk patient population., Methods: A retrospective study was performed on all patients in the University Hospital of North Staffordshire who underwent creation of a wrist or elbow fistula for HD. During the study period 289 primary AVFs were created. In all, 210 AVF were sited at the wrist and 79 at the elbow. Follow-up ranged from 3 months to 4 yrs. Primary patency and patient death, transplant and transfer were taken as end points. Patient survival was defined as time of fistula creation to patient death. Actuarial survival was calculated using Kaplan-Meier survival analyses, with differences between groups determined using log rank analysis, and statistical significance obtained using X2 tests., Results: Primary patency for wrist fistulae was 49, 41 and 32% at 6, 12 and 24 months, respectively, and 57, 51 and 38% for elbow fistulae. Regression analysis showed fistula survival to be significantly greater in males than in females (p=0.023). Fistula survival rates in non-diabetics patients were higher than in patients with diabetes however, this was not significant (p=0.11); (54, 48 and 34% in diabetics compared to 45, 35 and 26% in non-diabetics at 6, 12 and 24 months, respectively). Age did not influence fistula survival; however, it did affect patient survival. Patient survival was 90, 74 and 56% at 1, 2 and 3 yrs, respectively, and in >60s fell to 86, 71 and 50%. Overall 74/245 (30%) patients died., Conclusion: These results suggest that overall primary patency rates for wrist and elbow fistulae are comparable to similar studies at 6, 12 and 24 months. Fistula survival after this period is dictated by poor patient survival. Our findings suggest that creation of primary vascular access at the elbow in older females and diabetics may be associated with better results.