Temporizing catheter use was associated with higher mortality, higher infection, and lower patency, thus undermining the highly prevalent approach of electively using catheters as a bridge to permanent access. Autogenous fistulas are associated with longer time to catheter-free dialysis but better patency, lower infection risk, and lower mortality compared with prosthetic grafts in the general population.

Current incident AVF practice falls exceedingly short years after recommendations were made in 1997. The impact of this shortcoming on mortality for patients with end-stage renal disease is enormous. Functioning permanent access at initiation of HD confers lower mortality even compared with patients temporized with an HC while awaiting maturation of permanent access. A change of current policies and structured multidisciplinary efforts are required to establish matured fistulae prior to HD to ameliorate this deficit in delivering care.

AAA repair should be approached with extreme caution in octogenarians. Perioperative and 1-year mortality rates after OAR are particularly high in the older population, suggesting that the appropriate aneurysm size threshold for OAR might be larger due to the greater operative risk in octogenarian patients.

Black patients and Hispanic patients tend to initiate hemodialysis with an AVF less frequently than white patients despite being younger and having fewer comorbidities. These disparities persisted independent of factors that drive health access for fistula placement, such as medical insurance status and nephrology care. The sociocultural underpinnings of these disparities deserve investigation and redress to maximize the benefits of initiating hemodialysis via fistula in patients with end-stage renal disease irrespective of race/ethnicity.

AVF is superior to AVG and HC regardless of the patient's age, including in octogenarians. In contrast, the mortality benefit of AVG over HC may not apply to younger (18-48 years) or older (>89 years) age groups. All patients 18 to 48 years should receive AVF for dialysis access whenever possible.

In this study of a recent cohort of patients who received arteriovenous grafts, primary and primary assisted patencies were similar between BCA and ePTFE grafts. However, secondary patency was higher for BCA, indicating better durability for the biologic graft than for ePTFE grafts in patients whose anatomy preclude placement of an arteriovenous fistula.

Objective: The objective of this study was to compare the outcomes of arteriovenous fistulas (AVFs) with arteriovenous grafts (AVGs) in a large population-based cohort of elderly patients in the United States.Methods: A retrospective analysis was performed of all patients $75 years old in the prospectively maintained United States Renal Database System who had an AVF or AVG placed for hemodialysis (HD) access between January 2007 and December 2011. Outcomes were mortality, conduit patency, maturation, time to catheter-free dialysis, and infection. A c 2 test, Student t-test, Kaplan-Meier analysis, and multivariable Cox regression analysis were employed.Results: Of the 124,421 patients studied, there were 19,173 (15%) AVF initiates, 4480 (4%) AVG initiates, 29,872 (24%) AVF converts, 10,712 (9%) AVG converts, and 59,824 (48%) patients who persisted on HD catheters. Compared with AVF initiates, relative mortality was significantly higher for AVG initiates (adjusted hazard ratio [aHR], 1.24; P < .001), AVF converts (aHR, 1.36; P < .001), AVG converts (aHR, 1.62; P < .001), and catheter-persistent patients (aHR, 2.23; P < .001). Primary patency (aHR, 1.21; P < .001) and primary assisted patency (aHR, 1.31; P < .001) were higher for AVF. Secondary patency was higher for AVGs within the first 4 months (aHR, 1.12; P < .001) but higher for AVFs beyond that time point (aHR, 1.25; P < .001). Maturation rate and median time to maturation were 80% vs 84% (P < .001) and 46 vs 26 days (P < .001) for AVF vs AVG.Conclusions: Pre-emptive AVF remains the best mode of HD in elderly patients who can tolerate surgery. Patients who cannot tolerate pre-emptive surgery or have to initiate HD on an urgent basis with a catheter should convert to AVF when it is feasible if life expectancy is >4 months. If life expectancy is <4 months, surgical risk and quality of life should be considered in making the decision to persistently dialyze through HD catheter or to convert to AVG.

Conclusions: Drug-Coated balloon therapy is superior to percutaneous transluminal angioplasty in the treatment of patients using catheter based techniques for symptomatic femoral popliteal peripheral artery disease.Summary: Endovascular treatment of symptomatic peripheral arterial disease (PAD) is now accepted and in many cases recommended as a primary revascularization strategy in a wide range of clinical and anatomic scenarios. However, optimal methods of catheter based treatment for superficial femoral and popliteal artery disease remain controversial. Dynamic stresses applied by the superficial femoral and popliteal artery can result in stent fracture and in-stent restenosis. One approach, given these limitations of stenting, has been the use of drug-coated balloons to try and combine balloon dilatation with local delivery of an antiproliferative drug. In this study the authors compared a paclitaxel-coated balloon with percutaneous transluminal angioplasty (PTA) for treatment of symptomatic superficial femoral artery and/or popliteal artery disease. The IN.PACT SFA trial is a prospective, multicenter, single-blinded randomized trial of 331 patients with intermittent claudication or ischemic rest pain secondary to superficial femoral and/or popliteal PAD. Patients were randomly assigned in a 2 to 1 treatment ratio to drug-coated balloons (DCB) or PTA. Primary efficacy end point was primary patency defined as freedom from restenosis or clinically-driven target lesion revascularization at 12 months. Baseline characteristics were similar between the 2 groups. Mean lesion length and percent of total occlusions for the DCB and PTA trials were 8.94 6 4.89 and 8.81 6 5.12 cm (P ¼ .82) and 25.8% and 19.5% (P ¼ .22), respectively. DCB therapy resulted in higher primary patency vs PTA (82.2% vs 52.4%; P < .001). Clinically driven target lesion revascularization was 2.4% in the DCB arm compared with 20.6% in the PTA arm (P < .001). There was a low rate of vessel thrombosis in both arms (1.4% after DCB and 3.7% after PTA (P ¼ .10). There were no device-or procedural-related deaths and no amputations. At 12 months there were no significant differences between treatment groups in changes from baseline quality-of-life assessment. There was improvement in walking impairment in both groups at 12 months with similar functional outcomes at 12 months; however, PTA subjects required more clinically driven target lesion revascularization to achieve the same levels of functional outcomes as the DCB subjects. It is noted that the 2.4% target lesion revascularization rate of the DCB patients is the lowest reported for an SFA device trial at 12 months.Comment: The trial was composed primarily of patients with claudication and perhaps best serves as a proof of concept study. The results cannot be generalized to patients not included in the trial and cost effectiveness studies will be needed, However, it does appear drug-coated balloons will become an important treatment option for patients with superficial femoral and popliteal artery P...