Purpose of review: Achieving functioning vascular access in hemodialysis patients remains challenging. Current guidelines recommend creating arteriovenous fistulas (AVFs) as the initial form of vascular access and are primarily based on outdated, observational data. Determining the optimal access for each individual patient is, therefore, of great interest.
Recent findings: Multiple recent studies suggest that certain subgroups of patients may benefit from alternative forms of vascular access. In particular, the elderly and patients with limited life-expectancy may be less likely to benefit from an AVF first approach. These patients may be more likely to die before benefiting from an AVF and are more likely to experience primary failure of an AVF. If these factors are considered, arteriovenous grafts, and in some cases central venous catheters, become a valid alternative form of vascular access. Patients may also have strong opinions about each type of vascular access, leading to a preference for alternative forms of access.
Summary: A patient-centered approach to the choice of dialysis access that incorporates a balance between recent evidence from the literature and patient preferences may be preferred to the current fistula first focus in vascular access choice.