Addressing the Disconnect Between Reimbursement and Patient Value in Aortic Surgery

Abstract

Objectives: Arteriovenous fistulas (AVF) are the preferred access for patients who require hemodialysis. However, some AVFs require additional surgery to augment maturation. This study determined the effectiveness of AVF revision and the clinical characteristics of patients with poorly maturing fistulas. Methods: All AVFs performed over a 5-year period (January 2006-December 2011) were reviewed, classified as radial-cephalic (RC), brachial-cephalic (BC), brachialbasilic transposition (BVT), and brachial-brachial (BB). Technical factors and co-morbidities for patients with AVFs that matured without assistance were compared with fistulas that required revision or were abandoned. Data were evaluated on a per-patient basis (c 2 and t-test, P value <.05) Results: 292 AVFs were created in 250 patients. 134/250 fistulas (53.6%) matured without assistance within an average of 71 days. Patients with AVFs that matured without revision were more likely to be male (60.6% vs 42.1%; P < .01), have a lower BMI (26.9 vs 29.8; P < .01), and a larger preoperative vein diameter (3.83 mm vs 3.42 mm; P < .02). 54 of 116 non-matured AVFs were revised (70% RC, 26% BC, 4% BVT). The more common revisions were branch ligation (52%), superficial transposition (31%), and anastomotic revision (30%). 89% required one, 9% two, and 2% required three revisions to achieve maturation. Average time from index AVF creation to maturation in revised patients was 209 days. 42/54 patients (79.2%) developing a usable fistula, increasing the overall maturation rate to 70.4%. The most common cause for abandoning a non-mature fistula was thrombosis (62%). Conclusions: Surgical revision for poorly maturing AVFs increases overall fistula maturation rates as much as 17%.