Abstract

This article presents the rationale, challenges, and adaptive strategies employed during the initiation and execution of the AV Access trial—a multicenter randomized controlled trial (RCT) comparing arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) for hemodialysis in older adults with major comorbidities. Motivated by shifts in epidemiologic landscapes and evolving guidelines moving away from a Fistula First approach and to more patient-centric approaches, the objective of this RCT is to fill critical knowledge gaps in determining the optimal vascular access for this complex patient population. We outline the challenges encountered in patient recruitment along with measures employed to overcome these obstacles in recruitment. We emphasize the pivotal role of continuous research in overcoming these challenges, underscoring its necessity to achieve a thorough comprehension of optimal vascular access strategies for this complex patient population.