Severe steal develops immediately following AV bridge grafting and patients should be closely monitored during the first 24 h; surveillance is not indicated beyond 1 month. In contrast, steal following formation of proximal autogenous fistulae may be either of immediate or of 'late' onset, months or years after the creation of the fistulae, and lifelong monthly surveillance is recommended. Close monitoring is also recommended after any subsequent surgical or interventional correcting procedure for all access types. DRIL is the procedure of choice in limb-threatening severe steal.

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A proximal brachioaxillary prosthetic AV graft is a good alternative as initial primary access in elderly patients who are not suitable for an autologous proximal AV fistula. At this age long term patency and conservation of proximal access sites are of minimum importance because of their limited life expectancy.

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Objective:To study time-trends in vascular access surgery. Design: Prospectively registered data. Material and methods: The Swedish vascular registry (Swedvasc) was searched for haemodialysis access operations (HAO) 1987(HAO) -2006 Results: 12,342 open and endovascular operations were identified. Eighty-five percent of HAO 2004HAO -2006 were reported to the registry. The median age of patients having their first HAO increased from 56 to 68 during the first decade (p Ͻ 0.0001), then remained stable. The frequency of diabetes increased from 12% in 1987 to 32% in 2006 (p Ͻ 0.0001). The percentage of first HAO of total workload decreased from 76% to 48%. The percentage of first HAO performed as vein fistulas remained unchanged. The number of patients recorded for ten or more previous HAO increased over time. Percutaneous angioplasties increased during the last decade.Of 4706 patients operated on with primary radiocephalic AV-fistulas, 2933 (62%) were operated only once. Analysis of 3739 subsequent operations in 1773 patients disclosed that at the tenth operation vein was still used in 54%. With an increasing number of operations, arterial inflow shifted towards a more proximal position.Conclusions: Over time, the patients undergoing HAO became older and more often diabetic, reoperations increased. Despite these circumstances, vascular surgeons perform AV-fistulas without grafts in most patients.