Alternative Vascular Access Approaches

Vascular Access Hierarchy

• The American Journal of Kidney Diseases recommends considering an arteriovenous graft (AVG) as the next option when an arteriovenous fistula (AVF) is not possible, followed by a tunneled central venous catheter (CVC) only if no other options exist, due to lower infection rates and better outcomes 1, 2
• AVGs are preferred over tunneled CVCs due to lower infection rates and better outcomes, with a strength of evidence supporting this recommendation 3

AVG Placement Options

• The American Journal of Kidney Diseases suggests considering forearm loop graft, upper arm straight graft, and upper arm loop graft as AVG placement options, in order of preference 1

Tunneled CVC Placement

• The American Journal of Kidney Diseases recommends placing tunneled CVCs in the internal jugular vein, external jugular vein, femoral vein, subclavian vein, or lumbar vein, in order of preference, with right-sided placement generally preferred over left-sided 1, 4

Pitfalls to Avoid

• The Journal of the American College of Radiology warns against delaying AVG placement, as prolonged CVC use is associated with increased mortality and infection risk 6
• The Journal of the American College of Radiology advises assessing for central venous stenosis before AVG placement to ensure adequate outflow 4
• The Journal of the American College of Radiology emphasizes the importance of regular monitoring of AVG function to detect dysfunction early and prevent thrombosis 5

Management of AVG Complications

• The Journal of the American College of Radiology recommends managing stenosis/thrombosis with endovascular techniques or surgical revision 5