Are Early Cannulation Arteriovenous Grafts (ecAVG) a Viable Alternative to Tunnelled Central venous Catheters (TCVCs)? An Observational “Virtual Study” and Budget Impact Analysis

Abstract

Original articleprior to the anticipated date of dialysis commencement. If haemodialysis is required before this time, or if complications arise with the initial AVF creation (25%-35% of AVF fail at an early stage), then an alternative method of dialysis, generally via TCVC, is required (2).Dialysis via a TCVC confers significantly higher risk of infection, mortality and central venous stenosis than dialysis via an AVF. A recent national Scottish study of 2666 patients revealed a 2-to 3-fold increased risk in mortality (all-cause mortality, cardiovascular or infection related mortality) and a 7-fold increase in death from septicaemia with the use of TCVCs (3). The complications of vascular access are responsible for over 20% of all hospitalisations of patients on haemodialysis and account for one-third of all in-patient renal bed usage (4). It therefore follows that a strategy of TCVC minimisation or avoidance is likely to have significant benefits both to the individual and to the health service generally.Arteriovenous grafts (AVGs) may provide an alternative means of achieving vascular access in patients requiring

A randomized controlled trial and cost-effectiveness analysis of early cannulation arteriovenous grafts versus tunneled central venous catheters in patients requiring urgent vascular access for hemodialysis

“…The total number of hospital days were reduced in the ecAVGþ/ÀAVF cohort in the 6 months after graft insertion compared with the 6 months before ecAVG insertion (4 [IQR, 3-7] days vs 8 [IQR 4, 12] days; P ¼ .02). A similar trend was not seen in the TCVCþ/À AVF cohort (10 [IQR,(8)(9)(10)(11)(12)(13)(14) days vs 8 [IQR, 4-10] days). Initial HR-QoL scores were comparable at entry to the study (total EQ-5D: 67 6 12 vs 67 6 14; P ¼ .89).…”

“…19 Sample size calculation We postulated a reduced incidence of systemic bacteremia in the ecAVGþ/ÀAVF group. Using previously published bacteremia rates for TCVCs and ecAVG in our own institution, 9,10 we calculated that 53 patients would be needed in each group to provide 80% power to detect a reduction in the incidence of systemic bacteremia from 24% to 5% at 6 months of follow-up with an a ¼ .05. To account for attrition/loss to follow-up of 10%, we aimed to recruit 118 patients (n ¼ 59 per arm).…”

“…However, the recent development of early cannulation AVGs (ecAVGs) now allows grafts to be considered as an alternative to a TCVC in patients requiring vascular access imminently. 8,9 The benefits and limitations of an AVG lie somewhere between those of a TCVC and an AVF: they require significantly greater initial outlay in surgical expertise, time, and material cost 10 but have infection and complication rates lower than a TCVC. 11,12 Culture-proven bacteremia rates for TCVCs are 1.77/1000 catheter days compared with 0.6/ 1000 dialysis days for an AVG and 0.3/1000 dialysis days for an AVF.…”

“…Observational data suggests that such a strategy could deliver a cost savings of nearly £1000 per patient after 6 months. 10 We therefore designed a randomized controlled trial comparing ecAVGs vs TCVCs in patients requiring urgent vascular access for HD. We hypothesized that ecAVGs would result in a lower bacteremia rate than TCVCs and could potentially deliver cost savings.…”

Hemodialysis access cost comparisons among incident tunneled catheter patients

“…We find, as in the currently available literature, that AVG patients accrue more medical expenses than those with AVF. 1,4,5,15 Through identifying physician services payments for access creation and maintenance, in combination with overlapping payments for institutional claims, no significant difference in access-related costs were found between AVF and TDC; however, AVG remained the costliest access modality.…”