This is a general review of problems in vascular access and the role of the endovascular procedures vs surgery. In general to me the presentation is balanced. Authors appropriately point out where the data supporting one vs the other is lacking or sample size is too to small to make definite conclusions’. Reemphasizes to me the lack of collaboration among the members of ASDIN to develop simple protocols that could be done to combine data from active centers with good surgeons and interventionalists to answer these questions and to prove to CMS that what we do actually saves money for the government. We should abolish those strategies that are not cost effective like assisted maturation times 3, etc.

I found this article to be a useful summary, and generally in line with my experience as a full-time dialysis access surgeon. I would make a couple of points:
Every community or region will have a unique mixture of different specialists engaging in dialysis access care, with different training, different experiences, and different availability leading to a unique ecology of care. In one setting it is the interventionalist who refers given patients to the surgeon, in some settings the endovascular-equiped surgeon who refers patients to the interventional radiologist for specialized aervices, and in others a collaborative back-and-forth depending on availability. Communication is the key, and patterns will be different in each ecology.
Second, as reimbursement for dialysis access procedures plumments, full-time surgeons in this field have a harder and harder time covering their practice expenses, and a harder time making a living. It is no wonder that a pattern of cherry picking and patient dumping has grown, in my area at least. Surgeons literally cannot afford to take on a complicated four-hour case and get paid for 90 minutes, then manage the healing problems and other complications all rolled into a 90 day global payment. I am not overly surprised or angered when I hear the patients say of the previous surgeon, "He said 'We don't do that'", referring to a giant pulsatile aneurysm, or "He said if he operated on me I might die", or my personal favorite, "He just shook his head and walked away", declaring that the patient had no access options. Yet someone must take responsibility. Added to the fact that real experience in dialysis access problems is lacking in most training programs means that in many places the complex problems will go unmet, or be managed poorly. As a transplant-fellowship trained vascular access surgeon I never made as much as the "real" vascular surgeons, but in the last decade it dropped to half that, and after Covid I found myself earning less than the CRNAs I work with (time to audit my billing practices, for sure). Respect for my work hasn't been in cash, but in platitudes. Although I have heard it said, "Steal? We don't need a surgeon for that - we have the Miller procedure", I doubt that the Miller procedure will be adequate for some of the fistulas depicted in this article, and condemn the arrogance that prompted that remark. I forsee a dark future for dialysis patients.
A couple of minor points - primary failure rates of access creation cited in the article at 40-70% are an argument for picking the best and sidelining the rest - I doubt that these poor results come from Dr. John Lucas, or John Ross's work, nor from mine, where 90-95% success rates are usual. When Tom, Dick and Harry are lining up to take a go at creating fistulas because they have nothing else to do ("How hard could it be?"), you are going to get poorer results than you might from a real Vascular Access Center of Excellence. Unfortunately, our system promotes cottage industry balkanization of healthcare provision.
Last, early thrombosis of a new graft (not fistula) is not always a dire portent due to fluctuating volume and perfusion status in the perioperative period after general anesthesia - I usually reassure the patient, and do a percutaneous thrombectomy at 3 or 4 weeks, prepared to put a covered stent in the venous anastomosis if needed. Avoiding a general for the percutaneous procedure leads to greater physiologic stability and a generally more successful procedure.
For Dr. Trerotola - I miss the Arrow PTD. Nothing I've seen has done so well for me.