Surgical creation of upper extremity arteriovenous fistula and grafts: a narrative review

Background and Objective: Surgical creation of arteriovenous fistulas (AVF) and grafts (AVG) continues to be the mainstay access for hemodialysis (HD). Avoidance of dependence on dialysis catheters continues to be a worldwide mission in dialysis access. Importantly, there is no one-size-fits-all approach to hemodialysis access and each patient should undergo access creation that is patient-centered. The aim of this paper is to review the literature, current guidelines, and discuss the common types of upper extremity hemodialysis access and their reported outcomes. We will also share our institutional experience regarding the surgical creation of upper extremity hemodialysis access. Methods: The literature review incorporates twenty-seven relevant articles from 1997 to present and one case report series from 1966. Sources were gathered from electronic databases including PubMed, EMBASE, Medline, and Google Scholar. Only articles written in the English language were considered and study designs varied from current clinical guidelines, systematic and meta-analyses, randomized controlled trials, observational studies, and two main vascular surgery textbooks. Key Content and Findings: This review exclusively focuses on the surgical creation of upper extremity hemodialysis accesses. Creating a graft versus fistula ultimately is decided by the existing anatomy, and is centered around the need of the patient. Preoperatively, the patient should undergo a thorough history and physical exam, with special attention to any previous central venous access, as well as, delineating the vascular anatomy with ultrasound imaging. The major tenets of access creation are choosing the most distal site of the non-dominant upper extremity whenever possible; and ideally creation of an autogenous access is preferred over a prosthetic graft. Described in this review are multiple surgical approaches for upper extremity hemodialysis access creation and associated institutional practices performed by the surgeon author. In the postoperative period, follow up care and surveillance are imperative to preserve a functioning access. Conclusions: The most recent guidelines regarding hemodialysis access still favor arteriovenous fistula as the primary goal for patients with suitable anatomy. Preoperative evaluation including patient education, intraoperative ultrasound assessment, meticulous technique, and careful postoperative management are all paramount for successful access surgery. Dialysis access remains quite challenging, but with diligence the great majority of patients can be dialyzed without catheter dependence.