Reassessing Recommendations for Choice of Vascular Access

Abstract

Optimizing vascular access outcomes remains a major challenge, despite the accumulation of consensus guidelines during the past 20 years. The initial Kidney Disease Outcomes Quality Initiative guidelines published in 1997 (1) and updated in 2001 (2) and 2006 (3) as well as the "Fistula First Initiative" in 2003 (4) have consistently recommended preferential placement of arteriovenous fistulas (AVFs) over arteriovenous grafts (AVGs). There has been a gratifying increase in AVF use among patients on prevalent hemodialysis in the United States from 35% in 2003 to 63% in 2017 (4). Unfortunately, central vein catheter (CVC) use remains high at about 20% in patients on prevalent hemodialysis and 80% among patients on incident hemodialysis (4). There has also been an alarming increase in the frequency of percutaneous and surgical interventions to promote AVF maturation and maintain their long-term patency for hemodialysis (5). Several rationales for preferring AVFs over AVGs have been proposed: (1) AVFs have better longevity (6), (2) AVFs require fewer interventions to maintain longterm patency for hemodialysis (6), (3) patients dialyzing with an AVF have a lower mortality than those dialyzing with an AVG (7), and (4) patients with AVFs incur lower access-related costs (6,8). Recent publications have suggested that the purported advantages of AVFs over AVGs may be overstated, because they hold true only if the AVF successfully matures for dialysis use. AVFs fail to mature at higher rates than AVGs and require longer maturation times (6,8). A systematic review of observational studies published from 1996 to 2002 reported that approximately one third (20%-50%) of new AVFs failed to mature successfully for dialysis use (6). Subsequently, the Dialysis Access Consortium Fistula Study, a multicenter trial enrolling 877 United States patients on hemodialysis, reported in 2008 that 60% of new AVFs failed to mature successfully for dialysis within 6 months (9). Most recently, the Hemodialysis Fistula Maturation Study observed an unassisted AVF maturation rate of only 44% in 602 patients (10). As a consequence of their high nonmaturation rates, AVFs have a secondary patency similar to that of AVGs in an "intention-to-treat analysis" (11). Additionally, AVFs requiring interventions to promote maturation have shorter patency and require more frequent interventions to maintain their patency compared with AVFs that mature without an intervention

Survival and Prognostic Predictors of Primary Arteriovenous Fistula for Hemodialysis

“…1,2) The success of dialysis depends on the creation and maintenance of adequate vascular access for chronic use. Although a native arteriovenous fistula (AVF) is recommended by guidelines as the primary choice for long-term hemodialysis access with a steady increase of its use in many countries, [3][4][5] the ongoing challenge facing vascular surgeons is the difficulty in forecasting the types of AVFs that will successfully mature and have long-term survival.…”

Do arteriovenous fistulas increase cardiac risk?

“…For most patients on hemodialysis, a surgically constructed arteriovenous fistula (usually in either the forearm or upper arm) is the best option for vascular access. Alternative long‐term vascular access options are either an arteriovenous graft or tunneled dual‐lumen central venous line; these are either the best or the only option for a significant minority of patients on hemodialysis …”

“…Alternative long-term vascular access options are either an arteriovenous graft or tunneled dual-lumen central venous line; these are either the best or the only option for a significant minority of patients on hemodialysis. 1 While it is clear that the development of these forms of vascular access have made hemodialysis a viable long-term option, they are not without their challenges and significant drawbacks. In a "perfect" hemodialysis world, the access option most likely to last longest with fewest complications is an arteriovenous fistula-but even that option has a finite life, and is associated with the risk of important problems such as bleeding, infection, stenosis, aneurysms, and thrombosis, as well as significant cosmetic drawbacks.…”

Practice patterns of dialysis access and outcomes in patients wait-listed early for kidney transplantation

“…Several recent studies have challenged the Fistula First paradigm in hemodialysis patients in terms of survival [ 24 – 26 ], primary patency [ 27 , 28 ], and cost-effectiveness [ 29 , 30 ]. Findings from these studies provide further evidence in favor of a more patient-centered approach in vascular access choice, one that takes into account the likelihood of AV fistula maturation, the use of previous vascular accesses, the patient’s life expectancy, and their quality of life [ 31 – 34 ]. Nevertheless, attention has focused mainly on the choice between AV fistula and AV graft in the elderly, for whom catheter dependency is often an adverse outcome.…”