Guidelines

1. Patient Referral
Guideline 1.1. An early plan for venous preservation should be a substantial part of pre-dialysis care and education in any chronic kidney disease (CKD) patient regardless the choice of treatment modality (Evidence level IV).
Guideline 1.2. Every chronic renal failure patient, who have opted for haemodialysis, should start dialysis with a functioning vascular access (Evidence level III).
Guideline 1.3. Potential chronic haemodialysis (HD) patients should be ideally referred to the nephrologist and/or surgeon for preparing vascular access when they reach the stage 4 of their CKD (glomerular filtration rate

2. Pre-operative evaluation
Guideline 2.1. Clinical evaluation and non-invasive ultrasonography of upper extremity arteries and veins should be performed before vascular access creation (Evidence level II).
Guideline 2.2. Central vein imaging is indicated in patients with a history of previous central vein catheters (Evidence level IV).

3. Strategies for access creation
Guideline 3.1. The access should provide sufficient blood flow to perform adequate haemodialysis (Evidence level II).
Guideline 3.2. Autogenous arteriovenous fistulae should be preferred over AV grafts and AV grafts should be preferred over catheters (Evidence level III).
Guideline 3.3. The upper extremity arteriovenous fistula should be the preferred access and should be placed as distal as possible (Evidence level III).
Guideline 3.4. Fistula maturation should be monitored to allow pre-emptive intervention if needed (Evidence level III).

4. Role of nurses and staff in access management
Guideline 4.1. Nurses and medical staff should be involved in vein preservation and monitoring of the vascular access. Every patient with chronic kidney disease should have a declared plan for preserving the vascular access and potential access sites (Evidence level IV).
Guideline 4.2. Any staff involved in handling vascular access or cannulating veins in renal patients should be adequately trained and be in a continuous training scheme for access management (Evidence level IV).
Guideline 4.3. An autogenous fistula should be cannulated when adequate maturation has occurred (Evidence level III).
Guideline 4.4. The rope ladder technique should be used for cannulation of grafts (Evidence level III).

5. Surveillance of vascular access
Guideline 5.1. Prior to any cannulation,autogenous arteriovenous fistulae and grafts should be assessed by physical examination (Evidence level IV).
Guideline 5.2. Objective monitoring of access function should be performed at a regular base by measuring access flow (Evidence level II).

6. Diagnosis of stenoses in AV fistulae and AV grafts
Guideline 6.1. If a haemodynamically significant stenosis is suspected by physical examination and/or flow measurement, imaging should be performed as soon as possible (Evidence level III).
Guideline 6.2. Pre-emptive intervention should be performed percutaneously or surgically without further delay and imaging should be performed immediately before the intervention (Evidence level II).
Guideline 6.3. If the complete arterial inflow and venous outflow vessels need to be visualized, magnetic resonance angiography (MRA) should be performed (Evidence level III).

7. Treatment of stenosis and thrombosis in AV fistulae and AV grafts
Guideline 7.1. For venous outflow stenosis percutaneous transluminal angioplasty (PTA) is the first treatment option (Evidence level III).
Guideline 7.2. Thrombosed autogenous and graft fistulae should be treated either by interventional radiology or surgery. Individual centres should review their results and select the modality that produces the best results for that centre (Evidence level III).

8. Diagnosis and treatment of central venous obstruction
Guideline 8.1. If symptomatic central venous obstruction is suspected, angiography of the access and complete venous outflow tract should be performed (Evidence level III).
Guideline 8.2. Treatment should be performed by percutaneous intervention (Evidence level III).

9. Diagnosis and treatment of access-induced ischaemia
Guideline 9.1. Access-induced ischaemia should be detected by clinical investigation and the cause should be identified by both non-invasive imaging methods and angiography (Evidence level III).
Guideline 9.2. Enhancement of arterial inflow, access flow reduction and/or distal revascularization procedures are the therapeutic options. When the above methods fail, access ligation should be considered (Evidence level II).

10. Central venous access
Guideline 10.1. Central venous catheters should be inserted as a last resort in patients without a permanent access and the need for acute haemodialysis (Evidence level III).
Guideline 10.2. The percutaneous route should be used for both acute and chronic catheter insertion.Insertion should be guided by ultrasound. A plain X-Ray (chest or abdomen) should be performed before use to locate catheter and detect any complication (Evidence level II).
Guideline 10.3. The right internal jugular vein is the preferred location for insertion (Evidence level II).
Guideline 10.4. Non-tunnelled catheters should only be used in emergency situations and should be exchanged as soon as possible for tunnelled catheters (Evidence level III).

11. Management of central venous access complications
Guideline 11.1. Catheter dysfunction should be corrected by local fibrinolysis designed to restore flow patency. Repetitive catheter dysfunction requires local fibrinolysis with additional catheter imaging, microbiological assessment and systemic coagulation evaluation (Evidence level III).

12. Management of the infected vascular access
Guideline 12.1. Infection of autogenous AV fistulae without fever or bacteraemia should be treated by appropriate antibiotics for at least 2 weeks (Evidence level III).
Guideline 12.2. Infection of autogenous AV fistulae with fever and/or bacteraemia should be treated by appropriate antibiotics given intravenously for 2 weeks. Excision of the fistula is required in case of infected thrombi and/or septic emboli (Evidence level IV).
Guideline 12.3. Infected graft AVFs should be treated by appropriate antibiotics given intravenously for 2 weeks and continued orally for 4 weeks. Depending on the presence of bacteraemia and/or infected thrombi segmental explantation of the graft with bypass needs to be considered (Evidence level III).
Guideline 12.4. Anastomotic infection is an indication for total graft explantation (Evidence level II).
Guideline 12.5. Catheter removal must be considered when catheter infection is suspected.Immediate removal should be performed in nontunnelled catheters when infection is diagnosed
(Evidence level III).
Guideline 12.6. In tunnelled catheters with a short febrile and/or bacteraemic reaction, a delayed removal may be considered (Evidence level III).In septicaemia, immediate removal should be performed in tunnelled catheters as well.