Report of the Standardized Outcomes in Nephrology-Hemodialysis (SONG-HD) Consensus Workshop on Establishing a Core Outcome Measure for Hemodialysis Vascular Access.

Vascular access outcomes in hemodialysis are critically important for patients and clinicians, but frequently are neither patient relevant nor measured consistently in randomized trials. A Standardized Outcomes in Nephrology-Hemodialysis (SONG-HD) consensus workshop was convened to discuss the development of a core outcome measure for vascular access. 13 patients/caregivers and 46 professionals (clinicians, policy makers, industry representatives, and researchers) attended. Participants advocated for vascular access function to be a core outcome based on the broad applicability of function regardless of access type, involvement of a multidisciplinary team in achieving a functioning access, and the impact of access function on quality of life, survival, and other access-related outcomes. A core outcome measure for vascular access required demonstrable feasibility for implementation across different clinical and trial settings. Participants advocated for a practical and flexible outcome measure with a simple actionable definition. Integrating patients' values and preferences was warranted to enhance the relevance of the measure. Proposed outcome measures for function included "uninterrupted use of the access without the need for interventions" and "ability to receive prescribed dialysis," but not "access blood flow," which was deemed too expensive and unreliable. These recommendations will inform the definition and implementation of a core outcome measure for vascular access function in hemodialysis trials.

Vascular Access Outcomes Reported in Maintenance Hemodialysis Trials: A Systematic Review.

BACKGROUND: Many randomized controlled trials have been performed with the goal of improving outcomes related to hemodialysis vascular access. If the reported outcomes are relevant and measured consistently to allow comparison of interventions across trials, such trials can inform decision making. This study aimed to assess the scope and consistency of vascular access outcomes reported in contemporary hemodialysis trials. STUDY DESIGN: Systematic review. SETTING & POPULATION: Adults requiring maintenance hemodialysis. SELECTION CRITERIA: All randomized controlled trials and trial protocols reporting vascular access outcomes identified from ClinicalTrials.gov, Embase, MEDLINE, and the Cochrane Kidney and Transplant Specialized Register from January 2011 to June 2016. INTERVENTIONS: Any hemodialysis-related intervention. OUTCOMES: The frequency and characteristics of vascular access outcome measures were analyzed and classified. RESULTS: From 168 relevant trials, 1,426 access-related outcome measures were extracted and classified into 23 different outcomes. The 3 most common outcomes were function (136 [81%] trials), infection (63 [38%]), and maturation (31 [18%]). Function was measured in 489 different ways, but most frequently reported as "mean access blood flow (mL/min)" (37 [27%] trials) and "number of thromboses" (30 [22%]). Infection was assessed in 136 different ways, with "number of access-related infections" being the most common measure. Maturation was assessed in 44 different ways at 15 different time points and most commonly characterized by vein diameter and blood flow. Patient-reported outcomes, including pain (19 [11%]) and quality of life (5 [3%]), were reported infrequently. Only a minority of trials used previously standardized outcome definitions. LIMITATIONS: Restricted sampling frame for feasibility and focus on contemporary trials. CONCLUSIONS: The reporting of access outcomes in hemodialysis trials is very heterogeneous, with limited patient-reported outcomes and infrequent use of standardized outcome measures. Efforts to standardize outcome reporting for vascular access are critical to optimizing the comparability, reliability, and value of trial evidence to improve outcomes for patients requiring hemodialysis.

Establishing patient-specific criteria for selecting the optimal upper extremity vascular access procedure.

OBJECTIVE: The Kidney Disease Outcome Quality Initiative and Fistula First Breakthrough Initiative call for the indiscriminate creation of arteriovenous fistulas (AVFs) over arteriovenous grafts (AVGs) without providing patient-specific criteria for vascular access selection. Although the U.S. AVF rate has increased dramatically, several reports have found that this singular focus on increasing AVFs has resulted in increased AVF nonmaturation/early failure and a high prevalence of catheter dependence. The objective of this study was to determine the appropriateness of vascular access procedures in clinical scenarios constructed with combinations of relevant factors potentially influencing outcomes. METHODS: The RAND/UCLA Appropriateness Method was used. Accordingly, a comprehensive literature search was performed and a synthesis of results compiled. The RAND/UCLA Appropriateness Method was applied to 2088 AVF and 1728 AVG clinical scenarios with varying patient characteristics. Eleven international vascular access experts rated the appropriateness of each scenario in two rounds. On the basis of the distribution of the panelists' scores, each scenario was determined to be appropriate, inappropriate, or indeterminate. RESULTS: Panelists achieved agreement in 2964 (77.7%) scenarios; 860 (41%) AVF and 588 (34%) AVG scenarios were scored appropriate, 686 (33%) AVF and 480 (28%) AVG scenarios were scored inappropriate, and 542 (26%) AVF and 660 (38%) AVG scenarios were indeterminate. Younger age, larger outflow vein diameter, normal or obese body mass index (vs morbidly obese), larger inflow artery diameter, and higher patient functional status were associated with appropriateness of AVF creation. Older age, dialysis dependence, and smaller vein size were associated with appropriateness of AVG creation. Gender, diabetes, and coronary artery disease were not associated with AVF or AVG appropriateness. Dialysis status was not associated with AVF appropriateness. Body mass index and functional status were not associated with AVG appropriateness. To simulate the surgeon's decision-making, scenarios were combined to create situations with the same patient characteristics and both AVF and AVG options for access. Of these 864 clinical situations, 311 (36%) were rated appropriate for AVG but inappropriate or indeterminate for AVF. CONCLUSIONS: The results of this study indicate that patient-specific situations exist wherein AVG is as appropriate as or more appropriate than AVF. These results provide patient-specific recommendations for clinicians to optimize vascular access selection criteria, to standardize care, and to inform payers and policy. Indeterminate scenarios will guide future research.

Single-center results of a series of prosthetic axillary-axillary arteriovenous access grafts for hemodialysis.

OBJECTIVE: Prosthetic infraclavicular axillary-axillary arteriovenous access grafts are one of a number of complex dialysis access options in patients when all of the usual upper limb possibilities have been exhausted. We present a follow-up of 35 patients who received this access graft during a 9-year period. METHODS: Patients were identified from our own operation records. Follow-up data were gathered from their locally held electronic medical records. Primary and secondary patency were calculated using the Kaplan-Meier estimate. RESULTS: During the study period, 15 of the 35 patients in our cohort underwent one or more revision operations. Primary patency was estimated at 88% at 6 months, and the secondary patency rate estimate was 54% at 48 months. Twelve patients died during the study period; the grafts in 17 of the 23 remaining patients were in use at the conclusion of the study. CONCLUSIONS: Although this is a small cohort, our results suggest that prosthetic axillary-axillary arteriovenous access should be at least considered as a viable long-term option for hemodialysis patients.

Prospective controlled pilot study of arteriovenous fistula placement using the novel Optiflow device.

OBJECTIVE: Arteriovenous fistula (AVF) maturation failure remains a significant problem with reported early failure rates around 50%. Suboptimal hemodynamics, variable surgical skills, and technique dependency are widely believed to contribute to AVF nonmaturation. The Optiflow (Bioconnect Systems, Ambler, Pa) is a novel anastomotic device placed in situ that has potential for improving hemodynamics and standardizing AVF placement. We report results from a prospective nonrandomized controlled pilot study designed to investigate the safety and performance of the Optiflow. METHODS: Forty-one participants underwent AVF formation using either a 3-mm or 4-mm Optiflow and 39 matched control participants underwent AVF formation using the standard technique at two sites. Patients were observed for 90 days after AVF placement. The primary end point was unassisted maturation, which was defined as an outflow vein with a diameter ≥5 mm and blood flow ≥500 mL/min measured by Doppler ultrasound. The secondary performance end point was unassisted patency, and the primary safety end point was freedom from device-related serious adverse events. RESULTS: Unassisted maturation rates at 14, 42, and 90 days were 76%, 72%, and 68%, respectively, for the Optiflow group and 67%, 68%, and 76%, respectively, in the control group (P = .38, .69, and .47 at 14, 42, and 90 days). There was a trend to earlier maturation (assessed at 14 days) in the 4-mm Optiflow group compared with the control group (P = .059). There were no device-related serious adverse events. CONCLUSIONS: Maturation results for both the Optiflow and control groups were highly favorable compared with historical assisted maturation rates of approximately 50%. The Optiflow appears to be safe and effective in the placement of AVFs, with high maturation rates.

Neointimal hyperplasia and calcification in medium sized arteries in adult patients with chronic kidney disease.

The nature of arterial changes resulting in cardiovascular events and dialysis vascular access failures in adult predialysis patients is not well known. This study examined intimal changes, calcium deposition, and consequent stiffness in brachial and radial arteries of adult CKD patients. Ten brachial-artery and seven radial-artery specimens were obtained during fistula creation from nine predialysis and eight dialysis-dependent, nondiabetic patients; and age-gender matched controls undergoing coronary bypass grafts (6 radial) or kidney donation (6 renal). Arterial stiffness was measured at baseline. Vessel histology, morphometric analysis of intima-media, and direct quantification of calcium load was performed using standard techniques. Both predialysis and dialysis patients demonstrated significant arterial intimal hyperplasia with intima:media ratio higher than controls (0.13 ± 0.12 vs. 0.02 ± 0.05, p = 0.01). Calcium deposition was demonstrated on histology and the calcium content in patients was higher than controls (34.68 ± 26.86 vs. 10.95 ± 9.18 µg/µg, p = 0.003). The blood vessel calcium content correlated with arterial stiffness (r = 0.64, p = 0.018). This study for the first time describes, and suggests mechanistic linkage between, intimal hyperplasia, pathological calcium deposition, and increased functional arterial stiffness in dialysis and predialysis patients. Our research could serve as a unique window into the in vivo status of the uremic vasculature impacting fistula maturation and cardiovascular disease.

Do blood pressure levels and other patient characteristics influence native fistula patency?

Arteriovenous fistulas (AVFs) play an important role in access for hemodialysis, yet premature thrombosis is a challenge. This study identifies factors influencing primary patency in a series of AVF creations. Postoperative systolic blood pressure (BP) was of principal interest; demographical information, comorbidities, smoking status, warfarin, aspirin, clopidogrel, and statins were considered. A retrospective review of AVF creations performed by one surgeon between January 2008 and September 2010 was conducted. Fistula patency was denoted by a bruit and measured at 3 weeks and 12 months after surgery. One hundred and fifty-one AVF creations were studied; 134 fistulas (88.7%) were patent at 3 weeks and 85 (56.3%) at 12 months. The odds ratio (OR) for thrombosis at 12 months was 0.16 (95% CI: 0.04, 0.62; p = 0.008) among patients with a postoperative systolic BP of 120-139 mmHg compared with those with a BP of ≤ 119 mmHg. Patients taking warfarin yielded an OR of 5.71 at 3 weeks (95% CI: 1.20, 27.11; p = 0.028), and 3.33 at 12 months (95% CI: 1.01, 10.99; p = 0.048). No other variables were statistically significant. Patients with postoperative systolic BP of 120-139 mmHg showed a reduction in fistula thromboses compared with patients with a systolic BP of ≤ 119 mmHg. Patients on warfarin were less likely to maintain a patent fistula.

Arteriovenous fistula creation using the Optiflow vascular anastomosis device: a first in man pilot study.

Although arteriovenous fistulae are the preferred form of dialysis vascular access they continue to have significant problems with maturation failure. The Optiflow device is a sutureless anastomotic conduit which could potentially reduce surgical time and also standardize the surgical procedure. We report herein on the "First in Man" experience with the Optiflow device.

Successful early cannulation of a superficial femoral vein transposition angioaccess in a patient without other alternatives.

Early cannulation of a native fistula is defined by Dialysis Outcomes and Practice Patterns Study and Kidney Disease Outcomes and Quality Initiative as between 2 and 12 weeks postoperatively. We present a case of a patient in whom anatomical and hematological barriers prevented early cannulation graft placement, and in whom temporary catheterization was not feasible as a result of central venous occlusion. Successful cannulation at the fifth postoperative day of a native angioaccess was performed and the reasons and challenges faced behind this choice under the circumstances were discussed.

Pre-emptive angioaccess for haemodialysis in the elderly.

BACKGROUND: The fastest growing population group in the UK is the elderly, particularly those aged ≥ 80 years. The primary aim of this study was to assess if age was a determining factor for successful first dialysis through a pre-emptive angioaccess. The secondary aim was to investigate what risk factors are associated with angioaccess failure and to assess their patency and complications in three different age groups of patients who had pre-emptive angioaccess. METHODS: The study was carried out retrospectively on prospectively collected data for the period January 2006-December 2007. The study population included all patients who had pre-emptive angioaccess for haemodialysis during the time frame of the study. They were divided into three age groups including a control group (A) with age <70 years, a young old group (B) (70-79 years) and an old group (C) (≥80 years). Primary failure and primary, assisted primary and secondary patency rates were ascertained and compared using the Kaplan-Meier curves and log-rank testing. RESULTS: Of 243 patients who had a pre-emptive vascular access, 110 (45%), 82 (35%) and 51 (21%) patients were in Groups A, B and C, respectively. The rates of successful first dialysis through the angioaccess, excluding patients not in end-stage renal disease yet, or those who received pre-emptive kidney transplant were 88, 71 and 87% for Groups A, B and C, respectively (P > 0.05). There were six deaths before dialysis could be commenced. The primary, assisted primary and secondary patency rates after 12, 24 and 36 months did not show any significant difference between the groups (P > 0.05). CONCLUSIONS: Elderly patients should be considered for angioaccess as first line of venous access. Our study showed a successful first dialysis with angioaccess with failure and patency rates comparable to other age groups. However, we still recommend that patients >80 years old be assessed on a case-by-case basis.

Early cannulation grafts in straight axillo-axillary angioaccesses avoid central catheter insertions.

The need for early cannulation grafts exists to prevent use of central venous catheters. We report our experience in patients who had a straight axillo-axillary angioaccess. All patients who have undergone an early cannulation axillo-axillary angioaccess between 2008 and 2010 were reviewed. Fifteen patients had 16 procedures. Of these, eight were women and their mean age was 56. All patients had exhausted access options bilaterally. All had previous catheter insertions with either sepsis or jugular veins thrombosis. They all had an axillary artery to axillary vein angioaccess using an early cannulation graft. Flixene(®) (Atrium Medical, Hudson, NH, USA) was used in 10 cases, whereas Rapidax(®) (Vascutek Ltd., Renfrewshire, UK) in 6. In 12 cases, grafts were cannulated after 12 hours, in 4 after 24 hours (12 hours-8 days, mean 1.8 days). For Flixene(®) , mean delay to cannulation was 1.1 days, whereas 2.71 for Rapidax(®) (p < 0.05). Primary patency rates were 92.9% and 65.7% at 6 weeks and 1 year, respectively. Secondary patency rates were 92.9% and 83.5%. There was no significant difference in patency rates between grafts. Early cannulation grafts in a complex position are safe and efficient considering their patency and complication rates. It avoids using central venous catheters.

Brachial artery aneurysms associated with arteriovenous access for hemodialysis.

Brachial artery aneurysm (BAA) is a rare condition. We describe a series of cases of BAA with arteriovenous access. Thirteen patients were retrospectively identified between January 2006 and July 2009 using a patient database. All were associated with brachio-cephalic fistulas. Mean age was 51.2 +/- 13.8 years. Twelve males (93.3%) were identified. Characteristics were: diabetes 1, hypertension 8, hypercholesterolemia 2, ischemic heart disease 2, family history of aneurysmal disease 2. Five BAA developed after access ligation, eight while it was working, one after trauma. One was associated with a venous aneurysm. While the average life of the access was 161 +/- 115 months, the average time for BAA formation was 40 +/- 35.8 months. BAA was asymptomatic in three patients, whereas 10 presented with ischemic and neurologic symptoms. None presented with a rupture. All patients underwent surgical repair, seven an aneurysm excision and end-to-end reconstruction of the brachial artery. Venous conduits were utilized: four long saphenous veins, one cephalic, and one basilic vein. All patients had patent brachial arteries with a complete relief of symptoms at 14 months. BAA is a rare but significant complication of vascular access. The surgical approaches presented offer a reasonable outcome.

Retroesophageal internal jugular-to-internal jugular vein bypass for venous occlusion in a patient with complex hemodialysis access.

This report describes a right-hand dominant, self-dialyzing patient whose left brachiocephalic autogenous access was previously rescued for left brachiocephalic vein thrombosis with a bypass to the right internal jugular vein (IJV). After 1 year, the left IJV thrombosed, resulting in painful edema and venous dilatation. A retroesophageal IJV-IJV bypass was created, preserving the left brachiocephalic autogenous access.

Enormous brachio-cephalic arteriovenous fistula aneurysm after renal transplantation: case report and review of the literature.

Creation of arteriovenous fistulae provides readily available vascular access for haemodialysis in patients with end-stage renal disease. However, it is associated with various potentially serious complications if left unattended. We report a case of a 73-year-old male presenting with an enormous brachio-cephalic fistula aneurysm measuring 70-5.4 cm 20 years after successful renal transplantation. Despite attending regular renal outpatient clinic follow-up, this was only noticed as an incidental finding when the patient attended the emergency department after a fall that severely bruised his access. The patient subsequently underwent ligation with complete removal of the aneurismal fistula and discharged to a rehabilitation unit 3 days post-operatively. Systematic closure of an arteriovenous fistula should be considered in all patients after successful renal transplantation to avoid potentially catastrophic complications of an arteriovenous fistula. In patients in whom the closure of vascular access is contraindicated, it is crucial to regularly assess the status of any arteriovenous fistula when following up patients after renal transplantation.

Use of the femoral artery route for placement of temporary catheters for emergency haemodialysis when all usual central venous access sites are exhausted.

BACKGROUND: Urgent dialysis via a temporary central line may be impossible when all central veins are obstructed. METHODS: We report 10 patients (7 males and 3 females) over a 5-year period who lost all venous access sites, due to multiple peripheral venous thromboses with a superior vena cava obstruction or stenosis in 50%. These patients required urgent haemodialysis prior to general anaesthetic for a surgical intervention, but in all cases a traditional central venous line could not be used. They were therefore dialysed via a femoral artery catheter (FAC) before surgical rescue or creation of a more definite vascular access (VA). The median age of these patients was 64.7 years. None were suitable for peritoneal dialysis or urgent transplantation. Thirteen FACs (11F dual lumen dialysis catheter) were inserted into the common femoral artery. Both lumens were perfused continuously with heparinized saline (12 000 IU/24 h). All patients underwent a surgical procedure (rescue of previous access/creation of a new exotic one). First dialysis adequacy was assessed and compared to the rescued or new access. RESULTS: All patients had been on haemodialysis for a median period of 4.4 years. The mean number of previous access procedures was 17 (range 10-28). The duration of FAC use ranged from 1 to 12 days (mean 5 days). Dialysis adequacy was satisfactory for all patients. Seven patients had a complex vascular access formed and six had thrombectomy of their previous access. There were two complications related to FAC use, which were distal ischaemia and bleeding. Three patients died from access-related problems at 0, 4.6 and 15.0 months. Seven are still dialysed through their fistula or graft as outpatients with a mean follow-up of 14.0 months (range 0-50.9 months). CONCLUSION: Femoral artery dialysis is an effective means of haemodialysis as a method to bridge the gap before definitive vascular access formation when all other options have been exhausted.

High-output cardiac failure following insertion of right femoral artery to left femoral vein PTFE graft for haemodialysis: a case report.

Arteriovenous grafts used for hemodialysis can produce high-output cardiac failure as a result of shunting of blood through the dialysis access. The following case demonstrates that the problem can occur shortly after graft formation and improved with graft ligation. It caused haemodynamic compromise because of previously undiagnosed, underlying valvular heart disease. It also caused a diagnostic difficulty in the immediate postoperative period as it was mistaken for postsurgical hemorrhage.

Prosthetic axillary-axillary arteriovenous straight access (necklace graft) for difficult hemodialysis patients: a prospective single-center experience.

BACKGROUND: It is not uncommon for all usual upper limb autogenous access sites to fail, often in patients for whom neither peritoneal dialysis nor transplantation is an appropriate option. Axillary-axillary arteriovenous bypass grafts could be used as the last option before a thigh autogenous access even in case of unilateral central venous stenosis or obstruction. We describe our experience with this procedure in a series of patients. METHODS: A consecutive series of 18 patients for whom all possible arm accesses had failed and neither peritoneal dialysis nor transplantation was possible underwent a necklace graft formation over a 2.5-year period. All grafts implanted were 6 mm, internally reinforced prostheses made of expanded polytetrafluoroethylene (PTFE, Gore-Tex Intering Vascular Graft, W. L. Gore and Associates, Inc, Flagstaff, Ariz) anastomosed end to side the axillary artery and contralateral vein, and tunneled straight in the subcutaneous space before the sternum. All patients had bimonthly clinical examinations in which the thrill, bruit, skin, cannulation sites, and dialysis adequacy were reviewed. They also had at the same time a transonic assessment where graft flows and recirculation rates were measured. In case of low flow (<600 mL/min) or drop of 20% between two measurements or recirculation >5% a fistulogram was obtained, and an intervention was performed to restore patency. RESULTS: We operated on 10 males and 8 females; mean age was 55.1 years. The primary patency was 83% and 72.2%, and the secondary patency was 94.4% and 88.9% at 6 months and 1 year, respectively. Five successful surgical revisions were carried out for four clotted grafts and one post dialysis rupture. One surgical revision for thrombosis failed and one local infection lead to thrombosis and was not amenable to surgical revision. Three patients died of causes unrelated to their vascular access during the study period. CONCLUSION: The reasonable patency and minimal complications associated with these bypasses show that they are a valid option for complex patients. We advocate the use of this bypass in patients with exhaustion of all access possibilities in both arms with a patent superior vena cava, subclavian, and brachiocephalic veins. We also indicate it in case of unilateral central venous stenosis or obstruction with complete exhaustion of all other access possibilities on the contralateral side.

Is basilic vein transposition a real alternative to an arteriovenous bypass graft? A prospective study.

Basilic vein transpositions (BVTs) are considered to be superior to arteriovenous bypass grafts (AVGs). However, for the most part studies comparing BVTs to AVGs have been retrospective in design and without a set follow-up protocol. In this analysis, data were prospectively collected from patients with either a BVT or a brachio-axillary AVG. When all other native options were exhausted a BVT was performed if the vein had a diameter of 3 mm. All patients had bimonthly measurements of access inflow and recirculation using ultrasound dilution and were followed up for 2 years. Of 76 patients, 34 had a BVT and 42 an AVG (p > 0.05). BVT group: 12 were male, 22 female, the mean age was 62 and 26% were diabetic. AVG group: 22 were male, 20 female, the mean age was 57 and 56% were diabetic. The maturation delay was higher in the BVT group (6 weeks vs. 2 weeks). For the BVT and AVG groups, at 6, 12 and 24 months, respectively, primary patency was 90% vs. 76% (p < 0.05), 73% vs. 61% and 69% vs. 54% (p > 0.05). Assisted primary patency was 100% vs. 90% (p = 0.1201), 96% vs. 56% and 74% vs. 40% (p < 0.001). Secondary patency was 100% vs. 83%, 93% vs. 70% (p < 0.025) and 85% vs. 62% (p < 0.01). In the BVT group, 18 patients had 32 interventions for a total cost of $127,800, while in the AVG group, 27 patients had 54 interventions for a total cost of $227,300. This is the first prospective study to confirm that BVTs were cost effective and associated with better outcomes when compared with AVGs.

Hemodialysis access-related survival and morbidity in an elderly population in South West Thames, UK.

Elderly patients form the most rapidly expanding group of hemodialysis (HD) patients in Europe and the United States. There are initiatives to promote an increase in arteriovenous fistula (AVF) formation. There are concerns that elderly patients may have lower rates of surgical vascular access compared with younger patients due to risks of higher co-morbidities, surgical complications, and higher AVF nonuse rates. The aim of this study was to compare access-related survival and morbidity for dialysis catheters and AVFs and to evaluate the AVF nonuse rate in an elderly population. We have performed a retrospective analysis of access survival and morbidity in patients > or = 70 years of age, either on maintenance HD or predialysis with preemptive formation of surgical access. One hundred and forty-six patients had permanent HD access created during the 18-month study period, from 1 January 2006 to June 2007. There were 89 male and 57 female patients in whom 78 AVFs and 137 tunneled venous catheters were inserted. There was a significantly greater loss of vascular access due to infection in the catheter group compared with the AVF group (P<0.016). Access survival was also significantly prolonged in the AVF group (446 days, 95% confidence interval 405-487) compared with the catheter group (276 days, 95% confidence interval 240-313), P=0.001. The rate of nonuse of AVFs was low (16%). We conclude that an AVF is the preferred form of vascular access in elderly HD patients.

An arterioarterial prosthetic graft as an alternative option for haemodialysis access: a systematic review.

INTRODUCTION: All arteriovenous fistula/grafts options should be exhausted before haemodialysis is carried out via central venous catheters (CVC). CVCs carry high morbidity and mortality risks and in some patients, the central veins could be exhausted. In these patients, an arterioarterial prosthetic loop (AAPL) or straight graft can be the only option for haemodialysis. A systematic review was thus carried out to look at the use of arterioarterial graft for haemodialysis, with regards to dialysis adequacy, complications, and patency rates. METHODS: An electronic search was performed using the EMBASE and MEDLINE databases from inception until June 2017. Study retrieval was conducted according to PRISMA guidelines. RESULTS: A total of eight studies published between 1976 and 2017 were identified for pooled analysis. The studies were retrospective cohort in design and reported data on 151 patients. Primary patency rate ranged from 67%-94.5% at six months to 54%-61% at 36 months, with secondary patency rates from 83%-93% at six months to 72%-87% at 36 months. All studies documented satisfactory haemodialysis. Although limited by the size of the cohort of patients studied, patients with end-to-side grafts did not suffer from distal ischaemia when the graft occluded unlike patients who had their graft sutured as end-to-end. CONCLUSIONS: This review highlights the potential benefit of arterioarterial grafts for dialysis as an alternative vascular access option. As a result, this review calls for registry-based multicentre study to evaluate this treatment arm as an alternative option when all AVF/AVG options are exhausted.