The Best Thing We Could Do Is Not Need a Dialysis Access
Dr. John Ross has spent more than three decades helping shape the field of vascular access. A board-certified surgeon and founder of the Dialysis Access Institute in Orangeburg, South Carolina, he has served as principal investigator on numerous clinical trials, educated clinicians across the country, and played a pivotal role in establishing vascular access as a distinct subspecialty within nephrology care.
Dr. Ross is a founding member and former Vice President of the Vascular Access Society of the Americas, a recipient of the American Society of Diagnostic and Interventional Nephrology’s Lifetime Achievement Award, and serves on the editorial boards of The Journal of Vascular Access and Endovascular Today.
In this conversation with CKG’s Michelle Gilliland, Dr. Ross discusses the often-overlooked importance of dialysis access documentation, the critical role nurses play in clinical outcomes, emerging innovations in vascular access, and why he believes the impact of dialysis access on cardiac health deserves far greater attention.
The Critical Role of Documentation in Clinical Research
You’ve participated in numerous dialysis access trials. How does incomplete or inconsistent documentation of cannulation practices, access assessments, infiltrations, thrombosis events, and other access-related complications affect clinical trial outcomes and real-world evidence generation?
Nothing we do means anything unless somebody can get two needles into the access.
We’re not talking about catheters. We’re talking about fistulas, grafts, and new technologies designed to improve vascular access. We may perform a technically beautiful operation, but the access isn’t successful until someone can consistently cannulate it and deliver dialysis.
If it doesn’t work in the dialysis clinic, we’ve accomplished nothing.
Throughout my career, I’ve worked with dialysis nurses and technicians who had been performing cannulations for 10 or 15 years. Their skills were extraordinary. In fact, I remember one clinic where I couldn’t understand how we were achieving such exceptional fistula outcomes. I’d visit on Saturday mornings and watch the staff work. It wasn’t the surgery producing those results. It was the expertise of the nurses and technicians.
That’s why documentation matters so much.
When we evaluate technologies designed to accelerate fistula maturation or improve access performance, outcomes are directly influenced by the people performing the cannulations. I can’t overstate that.
Many newer grafts and biologic access products require precise cannulation techniques. A 15-gauge needle inserted incorrectly can damage a graft or fistula. What could have functioned successfully for years may be compromised by a single poor cannulation.
What Data Matters Most?
From a surgeon-investigator perspective, what vascular access data points are most frequently missing or inadequately documented, and how does that limit the evaluation of access performance and patient outcomes?
The fundamental question is simple: Is the access working?
Once the needles are in, we need two things from a dialysis access: adequate blood flow and a usable cannulation target.
Can the access support two-needle dialysis? Was cannulation straightforward or difficult? If you were scoring ease of cannulation on a scale of 1 to 10, where would it fall?
I also need to know what’s happening during treatment. Are we achieving adequate dialysis? Are machine alarms occurring frequently? Are venous pressures elevated? Is arterial pressure excessively negative?
The documentation should follow the entire experience from cannulation through dialysis and decannulation. When the needles are removed, is there prolonged bleeding? Is hemostasis achieved appropriately?
I also want to know what the clinician observes when evaluating the access. Can they feel a strong thrill? Some newer grafts produce less palpable feedback and may require auscultation instead.
Those observations are invaluable. Detailed documentation throughout the treatment process gives us a complete picture of how the access is functioning in the real world.
Innovations Shaping the Future of Vascular Access
Which recent innovations in vascular access show the greatest promise for improving long-term patency and patient quality of life?
Interestingly, our preferred access remains the same one introduced in 1966: the radiocephalic fistula.
That tells you just how effective that original design was.
At the same time, we’ve seen tremendous innovation. Percutaneous fistula creation technologies continue to advance. Devices such as WavelinQ have demonstrated what’s possible, and several next-generation systems are currently in clinical trials.
We’re also seeing devices designed to improve fistula maturation. Products like VASQ and VenoStep are positioned around the artery-vein anastomosis to optimize flow patterns and encourage successful development of the fistula. Early results have been encouraging, and large clinical trials are underway.
On the graft side, there’s been significant progress as well.
Traditional PTFE grafts have existed for decades, but manufacturers continue to refine them. Some are coated with heparin to reduce thrombosis risk. Others incorporate self-sealing technology, which has had a meaningful impact on dialysis operations.
One of the most popular innovations at our institution has been the self-sealing graft. Staff appreciate them because bleeding is dramatically reduced after needle removal. Patients can leave the dialysis unit faster, and for home dialysis patients, the experience is significantly less intimidating.
Biologic grafts may represent another major advancement. One promising technology, currently being evaluated in clinical trials, is designed to gradually disappear after implantation, leaving behind the patient’s own tissue as the conduit. Early international results have been impressive.
The goal is straightforward: create an access that is durable, resistant to infection, and easier to maintain while improving the patient’s quality of life.
Closing the Communication Gap
Where do communication breakdowns most commonly occur between surgeons and dialysis clinic teams?
We create the access, and then the patient goes somewhere else for dialysis.
That’s where the real test begins.
The most important communication revolves around identifying problems early. Are venous pressures increasing? Is dialysis adequacy declining? Are there new cannulation difficulties?
I need to know what the problem is so I can fix it.
Equally important is understanding the urgency. Is this an issue that should be evaluated immediately? Tomorrow? Next week?
The dialysis nurse is often best positioned to make that assessment because they’re the one seeing the patient regularly.
Communication also creates opportunities for collaboration. When a nurse identifies a subtle issue that leads us to discover a significant stenosis before thrombosis occurs, that’s a shared success. We should be calling that nurse back and saying, “You caught this early. Great job.”
That feedback loop is invaluable.
AI, EMRs, and the Future of Care Coordination
How should EMRs evolve to support better communication and coordination among dialysis nurses, nephrologists, interventionalists, and surgeons?
I’ve worked through both the paper-chart era and the electronic era.
Paper records weren’t perfect, but when knowledgeable people managed them, they worked surprisingly well.
Today, the challenge is information fragmentation. After a procedure, multiple stakeholders need updates. The dialysis unit needs information. The nephrologist needs information. The EMR needs information.
Eventually, I’d like to see AI integrated directly into the workflow.
I’d love to walk up to an EMR and simply ask, “Tell me about Mrs. Jones,” and receive a concise, clinically relevant summary.
In my personal life, I already use AI to stay informed. While driving, I’ll ask questions about developments in dialysis access and quickly receive information that may be worth investigating further.
That said, AI should augment clinical judgment, not replace it. Important decisions still require validation and critical review.
The Overlooked Impact of Vascular Access on the Heart
If you were designing the vascular access section of an EMR from scratch, what information would be mandatory to capture?
The area I believe we’re overlooking is cardiac health.
A functioning fistula may carry approximately one liter of blood per minute. That means the heart is pumping an enormous volume of additional blood around the clock, even though dialysis only occurs for a few hours each week.
We don’t talk enough about what that means over time.
I’ve seen patients who initially appeared healthy gradually develop symptoms of heart failure years after access creation. The question is: how much of that cardiac burden is attributable to the access itself?
I believe we should routinely monitor cardiac function in dialysis patients with fistulas and grafts.
When a patient develops shortness of breath or declining exercise tolerance, we should evaluate both the heart and the access.
An arteriovenous access isn’t simply an anatomical procedure. It’s a physiologic intervention that fundamentally changes blood flow dynamics throughout the body.
We need to better understand the long-term consequences.
If I were a dialysis patient, I would want regular echocardiograms and routine monitoring of access flow. Ultimately, it’s about preserving quality of life.
Looking Ahead: A Future Beyond Dialysis Access
What changes would you like to see in kidney care over the next five years?
The best dialysis access is the one that isn’t needed.
I’d like to see more transplants.
I often joke that the definition of love is someone willing to give you a kidney. Tell somebody, “I’d give you my kidney,” and they’ll call you right back.
But there’s truth behind the joke.
The happiest patients I see are those who receive successful transplants. They come back to clinic smiling, energized, living their lives again.
We’re also making progress with artificial kidneys, xenotransplantation research, and other transformative technologies.
For younger patients especially, my goal isn’t simply to create an access. My goal is to help bridge them to transplantation.
At the end of the day, what matters most is quality of life.
Patients want to spend time with their families. They want to see their grandchildren. They want enough energy to enjoy ordinary moments.
If we can help them do that, we’ve succeeded.
And if we look back 50 years from now, I suspect many of today’s procedures will seem primitive.
But until something better comes along, we’ll continue working to improve outcomes for the patients who depend on them.
Because the best thing we could do from a dialysis access perspective is make dialysis access unnecessary.