Effects of a More Selective Arteriovenous Fistula Strategy on Vascular Access Outcomes

Abstract

Background The optimal choice of initial vascular access—arteriovenous fistula (AVF) or graft (AVG)—remains controversial, particularly in patients initiating hemodialysis with a central vein catheter. Methods In a pragmatic observational study of patients who initiated hemodialysis with a central vein catheter and subsequently received an AVF or AVG, we compared a less selective vascular access strategy of maximizing AVF creation (period 1; 408 patients in 2004 through 2012) with a more selective policy of avoiding AVF creation if failure was likely (period 2; 284 patients in 2013 through 2019). Prespecified endpoints included frequency of vascular access procedures, access management costs, and duration of catheter dependence. We also compared access outcomes in all patients with an initial AVF or AVG in the two periods. Results An initial AVG placement was significantly more common in period 2 (41%) versus period 1 (28%). Frequency of all access procedures per 100 patient-years was significantly higher in patients with an initial AVF than an AVG in period 1 and lower in period 2. Median annual access management costs were significantly higher among AVF patients ($10,642) versus AVG patients ($6810) but significantly lower in period 2 ($5481 versus $8253, respectively). Years of catheter dependence per 100 patient-years was threefold higher in AVF versus AVG patients in period 1 (23.3 versus 8.1, respectively), but only 30% higher in period 2 (20.8 versus 16.0, respectively). When all patients were aggregated, the median annual access management cost was significantly lower in period 2 ($6757) than in period 1 ($9781). Conclusions A more selective approach to AVF placement reduces frequency of vascular access procedures and cost of access management.

Arteriovenous Access for Hemodialysis

“…Arteriovenous grafts have low rates of primary failure, sparing the need for CVCs; however, if an AVF is usable (particularly if no intervention is required to facilitate use), AVFs typically have better long-term patency (>2 years) compared with AVG. A selective approach to AVF creation reduces arteriovenous access procedures and cost of arteriovenous access management . Central venous catheters for hemodialysis should generally be used as short-term, temporary vascular access, including when an arteriovenous access is not usable or ready for dialysis; however, long-term CVCs may be used for patients undergoing hemodialysis who have valid reasons for their use, such as no other arteriovenous access options …”

Does the Primacy of the Fistula Still Prevail in an Aging Hemodialysis Population?

“…5 The present study of Allon et al advances this investigative line by comparing outcomes when a more selective strategy for AVF placement is pursued. 1 Their analysis involved two separate periods when patients, starting dialysis with a CVC, were selected either for AVF or AVG placement. The first period (2004-2012) adhered to the Fistula First initiative.…”