Technological innovation in vascular access surgery: a reflection on two recent developments

© Author(s) (or their employer(s)) 2022. No commercial reuse. See rights and permissions. Published by BMJ. INTRODUCTION The discipline of vascular access surgery can be defined as the facilitation of dialysis through rapid and easy access to a patient’s bloodstream. 2 This is one of the most fundamental diagnostic and therapeutic principles in the care of renal failure patients; however, instruments to achieve this in a controlled manner were only developed midway through the 17th century. By the early 20th century, the earliest dialysis machines had been created; however, haemodialysis could not continue beyond a couple of dozen treatments per patient—there was an exhaustion of access as the blood vessels would be ligated (‘tiedoff ’) after each treatment to prevent excessive bleeding. Modern vascular access methods were born in the 1950s when the first central venous catheters (CVCs—catheter entering a central vein), arteriovenous grafts (AVG—a synthetic tube connecting an artery and a vein) and native arteriovenous fistulas (AVF—a surgically created communication between an artery and a vein) were used. Technological advancement in these early stages focused on vascular anastomosis techniques and arteriovenous shunting (directing arterial blood through the venous system) materials to overcome access failure and thrombosis, respectively. The need for innovation to overcome the shortcomings of previous technologies or practices is an ongoing process—this report describes the driving forces behind two recent developments in the field of vascular access and evaluates their advantages and disadvantages against alternate technologies and their current use in clinical practice: ► The Hemodialysis Reliable Outflow (HeRO) graft—a twocomponent graft aiming to overcome the problem of central venous stenosis (luminal narrowing of the central veins). ► Percutaneous endovascular fistula creation—imageguided fistula creation aiming to avoid complications associated with open surgically created AVFs.