Delegates at this year’s Vascular Access Society of Britain and Ireland (VASBI) annual scientific meeting (24–25 September, Liverpool, UK) discussed and shared new data on one of the most contentious issues in dialysis access: the field’s increasing shift away from previous ‘fistula-first’ attitudes in favour of more patient-specific paradigms that acknowledge the important role played by arteriovenous grafts (AVGs) and central venous catheters (CVCs) as first-line strategies.
Sitting down with Renal Interventions at VASBI 2026, Nicholas Inston (Queen Elizabeth Hospital, Birmingham, UK) chose to focus on the significant space CVCs continue to occupy in vascular access algorithms—despite having been “maligned” for many years.
“We’ve got to start thinking more about the role for catheters and where they should be used,” Inston said. “We do use them—we use them in about a third of our patients, and up to half in some places—but we’re not talking about them. We’re not talking about the potential benefits; all we talk about is how catheters are bad and everyone has to have a fistula. But we’ve seen from studies presented here [at VASBI] that half the fistulas are not even used and people have a lot of problems with them.
“Catheters are an accepted part of nephrology care and, for that reason, we have a responsibility to start taking it seriously, doing research, finding out what the problems are and fixing them.”
Historically, according to Inston, infection risks and access dysfunction have been considered chief among these problems with CVCs. One factor that is believed to contribute significantly to CVCs ultimately becoming inadequate for dialysis access is fibrin sheath formation—a near-universal complication whereby a fibrous, protein-based buildup begins to form around the catheter within hours of insertion.
Left unaddressed, fibrin sheath restricts blood flow, triggers repeated clinical intervention and shortens the working life of the catheter. First documented more than 40 years ago, it has long been managed as a routine, unavoidable side-effect of catheter use, as opposed to being treated as a problem that can be solved within the context of clinical practice and device technology.
Inston described this state of affairs as “hugely frustrating”, adding that “patients should be angry”—which goes some way to explaining the nomenclature of the recently introduced Fight Fibrin Sheath (FFS) campaign, for which Inston is a spokesperson.
“Fibrin sheath is a massive issue that no one is talking about, hence our desire to start a campaign to tackle it once and for all,” he added. “Fibrin sheath develops in 80–100% of CVCs within the first week of insertion. This directly affects the 50–75% of dialysis patients who begin treatment on a catheter, the majority of whom still need one for their primary vascular access six or more months later.”
Inston also highlighted a recent global survey led by the Dialysis Catheter Collaborative, which found—across 111 clinicians in 37 countries—that 52% of those surveyed named fibrin sheath and thrombosis as the primary complication limiting catheter lifespan, ahead of infection (29%) and malposition (15%). Furthermore, just 38% said they were confident in the ability for current technology to prevent fibrin sheath, representing the lowest score of any complication tested.
“The harsh truth is that CVCs have been vilified despite their continued importance,” he commented. “We say it’s time for the community, including industry, to start looking at catheters again. The current situation is unacceptable and why this campaign exists.”
Latest data
At VASBI 2026, initial results from the OASIS randomised controlled trial (RCT) were shared with attendees by Maarten Snoeijs (Maastricht University, Maastricht, Netherlands). The trial set out to determine the best strategy for vascular access creation in elderly haemodialysis patients with limited life expectancy, comparing outcomes between first-line arteriovenous fistulas (AVFs), AVGs and CVCs.
Across a total of 165 patients who were ultimately randomised, the trial was adjudged to have been successful in enrolling its intended population, with at least 50% of patients in each group having died at follow-up and the median survival rate across the full study cohort being just 2.8 years.
While the trial’s primary endpoint—the number of access-related reinterventions per year in each group—is set to be presented further down the line, Snoeijs did share data from a key secondary metric: patient-reported outcomes. He disclosed that short-form vascular access questionnaire (SF-VAQ) scores were significantly better in the CVC group as compared to AVFs and AVGs with regard to a range of physical symptoms, including pain, bleeding, swelling and bruises (p<0.001). Providing additional detail, the presenter highlighted a 7% rate of access-related pain with CVCs, contrasting with rates of 31% and 38% with AVFs and AVGs, respectively. However, other endpoints, including the social/emotional component of the SF-VAQ as well as overall complication rates, were statistically similar across the three study groups.
The conclusion Snoeijs delivered following this was simple: from the perspective of patient satisfaction, catheters do better than fistulas for older individuals with limited life expectancy. He also posited that these findings differ from those generated by prior, observational studies that were hampered by selection biases—underlining the importance of RCTs in guiding shared decision-making.
“What this study shows is that catheters are very well tolerated and, in that particular subgroup, patients actually prefer them,” Inston averred. “That’s not to say that every patient should have a catheter, but those patients who elect or need to have a catheter for any reason need to be treated with the same level of priority that we assign to other things.”
Inston was also keen to stress that there is a dearth of high-level clinical research in this area, both in terms of sufficient data on the latest CVC technologies, and in terms of randomised studies comparing different access modalities in a direct and unbiased way.
“To do these studies properly, you’d need to have an intent-to-treat population, start at day zero, and see what those patients have,” he explained. “A lot of patients who have catheters have had fistulas and grafts already, and, by default, end up with a catheter as their last option—and that’s why they do worse. That’s why randomising a select group of patients and comparing like with like is a really good endeavour.”
Next steps
A panel of global thought leaders in the kidney care space debated these new OASIS data and the ongoing challenges of optimising vascular access at VASBI 2026. Inston himself was joined by Snoeijs alongside Charmaine Lok (University of Toronto, Toronto, Canada) and Karen Stevenson (University of Glasgow, Glasgow, UK) for this discussion, with session moderator Paul Gibbs (Queen Alexander Hospital, Portsmouth, UK) boldly asking: “Are fistulas going to become the exception rather than the rule?”
In response, Stevenson stated that the context of the patient population and the feasibility of other dialysis access options will likely dictate the answer to that question moving forward, while Lok—who led the 2020 introduction of the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines that partly instigated the field’s shift away from a ‘fistula-first’ mindset towards more individualised, holistic approaches—added that “you can never go wrong if you think about the patient and their life plan”.
“We know that a huge percentage of our dialysis patients are going to need a catheter—so, why don’t we create the best catheters possible?” commented Jeremy Crane (Imperial College London, London, UK), speaking to Renal Interventions shortly before handing over governance of VASBI to incoming president Jennifer Hanko (Belfast City Hospital, Belfast, UK). “It doesn’t necessarily mean that catheters are suddenly going to start taking the front seat and fistulas will take the backseat. People in the vascular access community feel that doing any trial looking at catheter design would be frowned upon, because catheters themselves are frowned upon. But, because we know that a certain percentage of people can’t have a native fistula or a graft, we should do our best to produce the best dialysis catheters that we can, and that’s going to require industry, research and innovation to be at the forefront of those efforts.”
Crane also described the aforementioned OASIS data as “common sense”, due to the fact that complications associated with CVCs are known to become increasingly prevalent over time as fibrin sheath and infection risks accumulate—meaning catheters are better-suited to elderly patients with a minimal remaining lifespan—before commenting that the trial could have a “monumental” impact if it is able to produce more long-term follow-up data on these patients.
“A big problem is that we have all stopped talking about this, and we’ve accepted that catheters are bad and that we’ll just put up with that,” Inston added. “What needs to happen—and it’s part of what we’re trying to do with the FFS campaign—is for people to start kicking the hornets’ nest. Everyone from the patient up [including clinicians, regulators and device manufacturers] has to begin asking questions about why a certain device is being used and, if that evidence isn’t there, we need to start driving efforts to generate that evidence.”
