Outcomes of arteriovenous fistulas and grafts with or without intervention before successful use

Abstract

Objective Arteriovenous fistulas (AVF) are considered superior to arteriovenous grafts (AVG) because of longer secondary patency after successful cannulation for dialysis. We evaluated whether access interventions before successful cannulation impact the relative longevity of AVF and AVG after successful use. Methods This retrospective study of a prospective database identified patients who initiated dialysis with a catheter, and subsequently had a permanent access (289 AVF and 310 AVG) placed between 1/1/06-12/31/11 and successfully cannulated for dialysis at a large medical center. Patients were followed until 6/30/14, and we evaluated the clinical outcomes (secondary patency and frequency of interventions) of the vascular accesses. Results An intervention before successful cannulation was required more frequently with AVF than with AVG (50.5 vs 17.7%; OR 4.74; 95% CI 3.26 to 6.86, P < .0001). As compared to AVF that matured without interventions, those that required intervention had shorter secondary patency after successful cannulation (HR 1.84; 95% CI 1.30–2.60, P < .0001) and required more interventions per year after successful use (RR 1.81; 95% CI 1.49–2.20, P < .0001). Similarly, AVG that required intervention before successful cannulation had shorter secondary patency than those without prior intervention (OR 1.98, 95% CI 1.52 to 4.02, P < .0001) and required more interventions per year after successful use (RR 1.49; 95% CI 1.27–1.74, P < .0001). AVF requiring intervention before maturation had inferior secondary patency as compared to AVG that were cannulated without prior intervention (HR 1.45, 95% CI 1.08 to 2.01, P = 0.01), but required fewer annual interventions after successful use (RR 0.57; 95% CI 0.49–0.66, P < .0001). Conclusions The patency advantage of AVF over AVG is no longer evident in patients requiring an AVF intervention prior to successful cannulation, but the AVF require fewer interventions after successful use.

Changes in the Profile of Endovascular Procedures Performed in Freestanding Dialysis Access Centers over 15 Years

“…There are several issues that have grown out of the push to increase AVF utilization that might explain this. In addition, multiple studies (22)(23)(24) have shown that a salvaged FTM-AVF requires additional interventions to maintain its patency. However, if all AVFs that are created are considered, the primary patency of AVFs and AVGs is comparable for the first year after creation because of AVF FTM (16)(17)(18).…”

Vascular Access Management for Haemodialysis: A Value-Based Approach from NephroCare Experience

“…It is not our intent to review factors implicated in these outcomes but only to provide some brief trends and facts. Autologous AVFs have better survival than synthetic AVGs considering both primary and secondary-assisted patency [48][49][50]. Median technical survival with AVFs ranges between 3 and 10 years compared to AVGs which range between 1 and 4 years.…”

Arteriovenous Grafts: Much Maligned But in Need of Reconsideration?

“…When an AVF is created in an obese patient, it frequently requires a subsequent transposition procedure to make it accessible for cannulation by the dialysis staff (26). A recent analysis from our center found that, as compared to AVFs that were cannulated without a prior intervention, those that required a transposition surgery had a shorter cumulative AVF patency and required more frequent interventions to maintain long-term patency for dialysis after successful cannulation (28). Placement of an AVG rather than an AVF in this population permits a single surgical procedure, faster access cannulation, and shorter catheter-dependence.…”