[Vascular access for chronic hemodialysis: current status and new directions in the Piedmont]. / Accessi vascolari per emodialisi cronica: situazione attuale e nuovi orientamenti in Piemonte.

ABSTRACT

Long survival on dialysis and wide admissions of very old and high risk patients, have focused attention to the problem of vascular access in uremic patients. The situation is critical in the USA, where PTFE/bovine grafts are utilized in about 75% of the cases. conversely, AV fistulas are the main type of access in Piedmont, where their use approaches 90% of the cases, Cimino-Brescia fistulas account for 58% of vascular accesses versus 25% and 9% of proximal AV fistulas and PTFE/bovine grafts, respectively. However, the latter progressively increase as age and time on dialysis increase. Snuff box fistulas are used only for 3% of the cases and this figure is steadily decreasing. In the meanwhile basilic vein superficializations, even if limited in numbers (1%), provided in some centres satisfactory results in term of survival and function. However, the type of access that deserved in the last few years the highest interest is the internal jugular vein cannulation (Canaud/Tesio catheter). In a preliminary series of 51 cannulations in 47 patients, this vascular access was permanent in 28 cases. A possible future routine utilization of jugular vein catheters is advisable in cases where a waiting period (up to a few months) is requested to allow a new fistula to mature or to maintain an empty abdomen in a patient temporarily withdrawn from peritoneal dialysis. Due to the heavy engagement for catheter maintenance and the high number of removals for systemic (9.8%) or skin exit infections (13.7%), a longer stay of indwelling catheters, although actually safe, should be limited to selected cases.