One of the great myths of vascular access is that of "permanent access". In truth, there is no such thing - there is "long-term access" (a graft, fistula or cuffed catheter) and "short term access" (a temporary catheter). Patients and practitioners frequently find themselves frustrated when they encounter problems with "permanent access" and apply unrealistic expectations to the situation. A clear understanding of the natural history of grafts and fistulas, coupled with a plan to deal with the problems that inevitably occur, is necessary if we are to avoid loss of access and the disruption of our normal lives that can occur.

Having a fistula may be like owing a Mercedes, and having a graft may be like owing a Chevy, but in both cases the automobile owner is obliged to keep up with ordinary maintenance or the auto will turn into a piece of junk - the responsible owner does regular oil changes, routine maintenance, and tire rotation. Everyone takes their car to the shop when a "funny sound" in the engine or wobble in the wheels develops - otherwise you find yourself by the side of the road waiting for the AAA tow truck to turn up.

No - dialysis access represents an important investment that we should monitor and protect, and the reality is that all access requires maintenance and regular repair. Industry figures show that patients with AV grafts require an average of 1-½ procedures a year to maintain dialysis access, AV fistulas less. As none of us likes the prospect of dreading and waiting for the next disaster to disrupt our lives, we would like a better way to monitor our vulnerabilities, predict our problems, and manage our lives.

How are we to know when to seek help with our dialysis access? Just as there are guidelines for auto maintenance, there are guidelines for monitoring the function of AV access. Sophisticated pressure monitoring, recirculation and clearance calculations, and flow measurements are being used in many units to identify patients in need of a diagnostic and corrective procedure. Monitoring of access performance and preemptive treatment of problems has been shown to lead to a reduction in hospitalizations, missed dialysis, and catheter placement.

The simplest measure is the clinical examination - something that can be done be the individual patient, his or her caretaker, the dialysis nurse or attending nephrologist. Evidence of problems with dialysis access should lead quickly to a fistulogram (needle puncture and x-ray of the shunt) and other corrective procedures, such as dilation of narrowings (venoplasty) or stent placement.

A change in mind-set that leads us to (1) expect a need for occasional intervention in our AV access, (2) watch for signs of graft or fistula problems, and (3) intervene electively and effectively to prevent loss of access will help "keep us on the road", and keep us out of the hospital waiting for an emergency procedure.