A more accurate descriptive and clinically useful diagnosis based upon pathophysiology for what is commonly referred to as venous outflow stenosis is inflow-outflow imbalance. In these cases, the total outflow capacity of the AV access is inadequate to handle the inflow volume (Qa) without an increase in pressure. The relative inadequacy of the access outflow capacity in comparison to Qa results in increased outflow resistance and a proportional increase in intraluminal pressure. The clinical indicators associated with venous stenosis are the resulting manifestations of this imbalance. The point at which this occurs is dependent upon variations in these two parameters-Qa and outflow resistance. The variations in these two parameters are considerable and reciprocal. Excessive Qa results in or can lead to an entire list of serious problems that adversely affect patient morbidity and mortality. Most studies dealing with AV access Qa reduction have been for the treatment of an existing condition rather than its prevention; however, prevention of disease rather than waiting for its development is an important tenet of medical practice. The resulting clinical picture of inflow-outflow imbalance is taken as an indication for corrective treatment. In the past, in most cases this has meant angioplasty to open the outflow if it is reduced; however, this clinical picture may be associated with an excessive Qa and angioplasty in these cases creates the risk for a further increase in Qa. It is the authors' opinion that access flow measurements should be a part of the evaluation of these cases prior to planning treatment. Using this information, a bimodal approach to primary treatment should be adopted involving either angioplasty for cases with a low or normal Qa or flow reduction in cases with an elevated Qa.

3rd Department of Internal Medicine Charles University Prague Czech Republic

Clinical Research UC Health University of Colorado Hospital Aurora CO USA

Department of Cardiovascular Surgery Weill Cornell Medical College Houston TX USA

Department of Medicine Emory University School of Medicine Atlanta GA USA

Department of Medicine LSU Health Shreveport Shreveport LA USA

Department of Medicine Rush University Medical Center Chicago IL USA

Department of Medicine University of Alabama Birmingham AL USA

Department of Medicine University of North Carolina Chapel Hill NC USA

Department of Medicine University of Texas Medical Branch Galveston TX USA

Department of Medicine Weill Cornell Medical College Houston TX USA

Department of Radiology Palo Alto Medical Foundation Palo Alto CA USA

Department of Radiology University of Toronto Toronto ON Canada

Department of Surgery University of Oklahoma College of Medicine Tulsa OK USA

Department of Surgery Washington University School of Medicine St Louis MO USA

Dialysis Access Institute Orangeburg Regional Medical Center Orangeburg SC USA

Vascular Access Center Asklepios Clinic Barmbek Hamburg Germany

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