Thoughts on the Integrated Management of Vascular Access in Elderly Patients with Maintenance Hemodialysis (MHD)

Background: Although the use of arteriovenous fistulas (AVFs) has better clinical outcomes in the general hemodialysis population, the use of AVFs is uniquely challenging due to the high rate of immature vascular access and limited life expectancy in older hemodialysis patients. Methods: This article reviews the vascular access development plan and clinical data of 6 elderly patients, and summarizes the integrated vascular access management strategies of elderly patients with MHD based on literature review and guideline recommendations. Results: Case 1: Male patient with renal transplantation failure 10 years after kidney transplantation, who had previously had right AVF occlusion and the left side could not meet the establishment conditions, established the ulnar AVF of the right forearm after comprehensive evaluation, and started using it one month after surgery, and had good function. Case 2: Male patient with stage 5 CKD, diabetes, hepertension, coronary heart disease and gastric cancer, his left forearm catheter over 1 month, the right internal jugular vein TCC + left forearm ulnar AVF was established, and the AVF was started 3 months after surgery and the TCC was removed. Case 3: Male patient with CKD stage 5 stage and diabetes mellitus, in order to establish AVF in advance, and the left forearm blood vessel did not meet the surgical conditions, and the right cephalic vein branch was multiple and relatively tortuous, and the right radial artery-cephalic vein AVF was established in the first stage, and the fistula began to be used normally within 1 month after the re-examination was reconstructed and repaired after the tortuous cephalic vein was reconstructed and repaired. Case 4: Female patient with CKD stage 5 who underwent regular hemodialysis with TCC for 2 months were required to be admitted to the hospital with AVG, evaluated that the left radial artery, especially the cephalic vein, did not meet the surgical conditions, and the right vascular condition was acceptable. Conclusion: We believe that it is necessary to comprehensively consider the basic conditions of elderly patients. Individualized planning and implementation of designated vascular access and standardized postoperative follow-up. Regardless of whether the catheter is started for hemodialysis, the possibility of AVF or AVG should be comprehensively evaluated. Standardize the clinical pathway for the use of arteriovenous fistula.