Rationale for Guideline for "Preferred Vascular Access"

Vascular Access

Contribution from the Caring for Australians with Renal Impairment (CARI) Guidelines Committee

The 2000 CARI guideline on vascular access recommends:

• A native fistula is superior to an artificial arteriovenous graft.

Rationale: The CARI Vascular Access guidelines were published in March 2000 and are currently being updated. Both the KDOQI and Canadian Society of nephrology haemodialysis guidelines (CSN) have been updated very recently (July and March 2006 respectively) and make use of data that wasn’t available at the time of CARI guideline development. All advocate the native arteriovenous fistula (AVF) as the preferred vascular access. However, the KDOQI guidelines list arteriovenous synthetic graft (AVG) as acceptable whereas the CARI guidelines emphasize the AVF in preference until all upper arm sites have been exhausted. The CSN give the AVG and transposed brachiobasilic AVF equal weighing. While all guidelines emphasize the need for adequate planning and placement of AVF well before the anticipated need for dialysis, both KDOQI and CSN are more specific on the quantifying of the timing while CARI recognizes that the exact timing of placement is dependent on a number of factors and that the evidence supporting this guideline is of a lower level (Level III).

The major difference between the CARI and the other guidelines occurs in relationship to vascular access surveillance. CARI does not specify techniques for vascular access surveillance, stating that each unit should practice clinical evaluation of access and develop familiarity with a technique for determining access malfunction. Both KDOQI and CSN recommend direct vascular access flow measurements as the preferred surveillance technique for both AVF and AVG. This data is based on several randomised trials published since 2000. Therefore this difference may change with the updating of the CARI guidelines due in early 2007.

Prepared on behalf of CARI by Kevan Polkinghorne, Co-Convenor of CARI Vascular Access Guidelines Working Group