Relevance of a skilled vascular surgeon and optimized facility practices in the long-term patency of arteriovenous fistulas: a prospective study

Abstract

Introduction: Arteriovenous fistulas (AVF) are the best hemodialysis vascular accesses, but their failure rate remains high. Few studies have addressed the role of the vascular surgeon's skills and the facility's practices. We aimed to study these factors, with the hypothesis that the surgeon's skills and facility practices would have an important role in primary failure and patency rates at 12 months, respectively. Methods: This was a single-center, prospective cohort study carried out from March 2005 to March 2017. Only incident patients were included. A single surgeon made all AVFs, either in the forearm (lower) or the elbow (upper). Vascular access definitions were in accordance with the North American Vascular Access Consortium. Results: We studied 113 AVFs (65% lower) from 106 patients (39% diabetics, 58% started with catheter). Time to first connection was 21.5 days (IR: 14 - 31). Only 14 AVFs (12.4%) underwent primary failure and 18 failed during the first year. Functional primary patency rate was 80.9% (SE 4.1) whereas primary unassisted patency rate, which included PF, was 70.6% (4.4). Logistic regression showed that diabetes (OR = 3.3, 95%CI 1.38 - 7.88, p = .007) and forearm location (OR = 3.03, 95CI% 1.05 - 8.76, p = 0.04) were predictors of AVF failure. Patency of lower and upper AVFs was similar in non-diabetics, while patency in diabetics with lower AVFs was under 50%. (p = 0.003). Conclusions: Results suggest that a long-lasting, suitable AVF is feasible in almost all patients. The surgeon's skills and facility practices can have an important role in the long term outcome of AVF.

The association between the locations of arteriovenous fistulas and patency rates: A systematic review and meta‐analysis

“…In contrast, the non‐Asian group had higher PP and CP of AVF in upper‐arm than forearm at 1 and 2 years, which is consistent with the DOPPS study and might be due to the higher maturation rates of AVF in the forearm in the Asian group with fewer surgical interventions to assist maturation 11 . In a Singaporean study, it was found that only women with diabetes had lower PP in FA‐AVF than in UV‐AVF, which might be associated with the smaller diameter of arteries in women and atherosclerosis in diabetes being more severe in the distal extremities 21 . Moreover, the proportion of diabetic patients in the Asian group was lower than that in the non‐Asian group, which might explain to certain extent the similar patency rates of FA‐AVF and UV‐AVF in Asian group 21,24,31 …”

“…11 In a Singaporean study, it was found that only women with diabetes had lower PP in FA-AVF than in UV-AVF, which might be associated with the smaller diameter of arteries in women and atherosclerosis in diabetes being more severe in the distal extremities. 21 Moreover, the proportion of diabetic patients in the Asian group was lower than that in the non-Asian group, which might explain to certain extent the similar patency rates of FA-AVF and UV-AVF in Asian group. 21,24,31 When the design was analyzed as a subgroup, the difference in PP between the UA and FA-AVF at 1 and 2 years in the prospective study was not statistically significant, and CP in the prospective study was not available due to a lack of relevant literature.…”

“…21 Moreover, the proportion of diabetic patients in the Asian group was lower than that in the non-Asian group, which might explain to certain extent the similar patency rates of FA-AVF and UV-AVF in Asian group. 21,24,31 When the design was analyzed as a subgroup, the difference in PP between the UA and FA-AVF at 1 and 2 years in the prospective study was not statistically significant, and CP in the prospective study was not available due to a lack of relevant literature. In the included studies, it was revealed that AVF in the forearm, especially in small vessel diameters, could be significantly improved in terms of PP and maturation rates after specific trial design and rigorous monitoring.…”

“…Of the remaining 47 articles, 6 were excluded because they were not human experiments, 8 studies were deleted because they selected unsuitable inclusion criteria, 7 articles were excluded as only the upper-arm group or forearm group in their study, 12 articles were excluded as data cannot be converted or extracted in the study, and 2 was removed because they were literature reviews. Finally, a total of 12 studies [16][17][18][19][20][21][22][23][24][25][26][27] were deemed eligible for inclusion in this review (Figure 1).…”

Long-Term AVF Patency - Can we do better?

“…Siga E et al have focused on the importance of a multidisciplinary access team inclusive of a dedicated surgeon towards creating a successful AVF4. The primary unassisted and functional primary patency rates in their series of 113 AVF created by a single surgeon and same support team over a 12-year period was 70.6% and 80.9% respectively.…”