Access Creation Strategy

Abstract

Recommendations from several international societies are available on the best strategy to adopt when planning vascular access. However, all of them fail to mention the autogenous ulnar–basilic fistula at the wrist and the techniques of arterialized vein superficialization in the forearm. Every time a vascular access is created or revised, the logic and planning should focus on the possibilities for future access creation once the current one fails. The approach therefore should be to create forearm AVFs first and avoid any procedure that may compromise the venous outflow. Vascular access guideline recommendations then stipulate that an upper arm cephalic AVF must be considered whenever creation of a radial–cephalic fistula is not technically possible or fails in both forearms. In France, the option of creating a wrist ulnar–basilic AVF is considered before moving onto the elbow. A brachial–basilic AVF with mandatory superficialization should be the next consideration whenever forearm or brachial–cephalic AVFs are not possible. A prosthetic graft connecting the brachial artery to an upper arm vein should be considered as a last resort. Lower limb followed by exotic accesses are next considered after all upper limb options have been exhausted.