Conflict of interest

peripheral vascular disease [146]. In 40 patients with stenotic AVFs and AVGs, PCB angioplasty resulted in better target lesion and circuit primary patency rates at 6 months compared to high pressure balloon (HPB) angioplasty (70% vs 25% respectively, p < 0.001) [124] . Lai et al. [147] also reported improved AVF patency rate at 6 months in 10 patients (70% vs 0%, p < 0.01) although this was no longer statistically significant at 12 months (20% vs 0%, P > 0.05). A subsequent single center RCT by Kitou et al. [123] randomized 40 patients to receive PCB angioplasty or HPB angioplasty for dysfunctional AVFs, with a 12-month follow-up (Table 1). Primary endpoints included device success, anatomic success, clinical success and target lesion revascularization-free survival with secondary endpoints of dialysis circuit primary patency and procedure related complications [123]. Use of PCB

angioplasty in dysfunctional AVFs resulted in superior target lesion

larger RCTs currently prevent its routine use in clinical practice.

5. Process of care and individualization

Vascular Access Surgery - Tips and Tricks

minimizing the risk of infection.

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revascularization-free survival (PCB 308 days; HPB 161 days; HR 0.478; 95% CI 0.236–0.966, p = 0.03) and dialysis access circuit primary patency (PCB 270 days; HPB 161 days; HR 0.479; 95% CI 0.237–0.968; p = 0.04) in comparison to HPB angioplasty, though, additional HPB post dilatation was required in 65% of cases. Current trial results support the use of PCB angioplasty to prevent re-stenosis in AVF. However, higher costs compared to conventional angioplasty and the lack of

Systemic and local therapies to improve arteriovenous access outcomes have been limited, as outlined above. A multipronged approach including optimization of process of care may be more powerful to increase the use of AVFs or AVGs, as opposed to CVCs, than a single therapeutic intervention. An integrated approach to arteriovenous access care which included nephrologists, vascular surgeons, radiologists, access coordinators, and scheduled access procedures with tracked outcomes was demonstrated by Allon et al. [148] to reduce complications associated with surgical access procedures. These benefits included a 60% decreased rate of AVG thrombosis, improved graft secondary patency procedures, and an increase in the AVF creation rate from 33 to 69%. Arora et al. [149] found that patients who were referred to a nephrologist at least 4 months prior to dialysis initiation were 10 times more likely to have a successful functioning access at the first dialysis session, with 40% in the early referral group initiating dialysis with permanent vascular access (80% AVFs, 20% AVGs) vs 4% in the late referral group. This was supported by Roubicek at el [150] who found that 53% of patients referred early for arteriovenous access creation had functional AVFs vs 12% who were referred late. Having a vascular access coordinator can improve the number of AVFs created and decrease vascular access-related hospitalizations and infections [151]. Other strategies, including vein preservation policies, patient education regarding vein protection and access care, preoperative vein mapping and timely access creation have been found to increase fistula prevalence, decrease primary vascular access failure and increase cumulative patency [152–154]. The literature suggest that superior arteriovenous access success is achieved when the AVF is created by a skilled vascular surgeon, [45–49], with the emphasis being placed on the number of AVFs created over the total years of training [48, 50]. In the post-operative setting, timely assessment of arteriovenous access at 4 weeks is recommended to ensure access function is adequate, and to enable early surgical or endovascular intervention to prevent or treat primary access failure. Finally, arteriovenous access cannulation by appropriately trained staff has been shown to prolong AVF survival, while also

The authors have no conflict of interest to declare.
