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Over the past decade, there has been a resurgence of interest by nephrologists in the management of hemodialysis vascular access. The early days of dialysis were marked by advances in vascular access conceived and developed by visionary nephrologists, including the Scribner shunt and the Brescia-Cimino arteriovenous (AV) fistula. Without these means of obtaining reliable repeated blood access, the delivery of chronic hemodialysis would not have been possible. Some nephrologists have maintained this primary role in the creation and maintenance of vascular access, particularly in Europe. One successful example reported the construction of a series of 748 consecutive native AV fistulas, with 2 year assisted access survival rates in diabetics and nondiabetics ranging from 75% to 96%. During the 1970s and 1980s, at least in the United States, interest and involvement in vascular access largely faded. This may have been due to exciting progress in what were perceived to be more scientifically rewarding areas of study, as opposed to the relatively mundane “plumbing” problems of vascular access. Certainly neither technical proficiency nor rigorous academic attention to vascular access was emphasized in most nephrology training centers in the United States during that time. In many programs and practices management of vascular access was left exclusively to the surgeons. At the same time, particularly in the United States, there was increased promotion and utilization of synthetic polytetrafluoroethylene (PTFE) grafts in favor of native AV fistulas. This shift may have been driven by marketing and reimbursement practices, poor long-term venous access catheters available for use as “bridges” to native fistulae, and increasing emphasis on short, high efficiency dialysis treatments. The result for the United States nephrology community was a large hemodialysis patient population with a high prevalence of PTFE grafts, a low usage of AV fistulas, and perhaps incidentally, the highest dialysis patient mortality of all industrialized nations. In 1999, 49% of hemodialysis patients in the United States were dialyzing with AV grafts, 28% with native fistulas, and 23% with venous catheters.

During this period of a rapidly growing hemodialysis patient population, increasing PTFE graft utilization, and decreased involvement of nephrologists in the management of vascular access problems, there was a predictable crisis in the access-related medical care of these patients. Management of access dysfunction and thrombosis was largely “reactive” and primarily utilized open surgical techniques. The role of venous stenosis in contributing to AV graft thrombosis and failure was underappreciated. In the late 1980s, interventional radiologists began to recognize these problems and applied their tools and techniques to treating access dysfunction. A method for declotting AV hemodialysis grafts using pharmacomechanical thrombolysis and angioplasty was reported in 1991. Numerous other reports and variations on this method followed, with increasing acceptance of percutaneous interventions in the management of hemodialysis access dysfunction. Largely, however, nephrologists remained on the periphery, as vascular access continued to be the province of the vascular surgeon and more recently interventional radiologists. This collaboration of expert subspecialties might have been all that was needed to provide ...

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