Synthetic Vascular Hemodialysis Access Versus Native Arteriovenous Fistula

Abstract

Objective To determine the cost-effectiveness of two different vascular access strategies among incident dialysis patients. Summary Background Data Vascular access is a principal cause of morbidity and cost in hemodialysis patients. Recent guidelines and initiatives are intended to increase the proportion of patients with a fistula. However, there is growing awareness of the high prevalence of fistula failures and attendant complications. Methods A decision analysis using a Markov model was implemented to compare two different vascular access strategies among incident dialysis patients: a) placing an arteriovenous fistula (AVF1st) as the initial access followed by a synthetic vascular access if the AVF did not mature compared to b) placing a synthetic vascular access (SVA1st) as the initial access device. The cost-utility was evaluated across a range of the risk of complications from temporary catheters and SVA. Results Under base case assumptions, the AVF1st strategy yielded 2.19 QALYs compared to 2.06 QALYs from the SVA1st strategy. The incremental cost-effectiveness was $9389/QALY for AVF1st compared to SVA1st and was less than $50,000 per QALY as long as the probability of maturation is 36% or greater. AVF1st was the dominant strategy when the AVF maturation rate was 69% or greater. Conclusion The high risk of complications of temporary catheters and the overall low AVF maturation rate explain why a universal policy of AVF 1st for all incident dialysis patients may not optimize clinical outcomes. Strong consideration should be given to a more patient-centered approach taking into account the likelihood of AVF maturation.

Arteriovenous Fistula Maturation in Prevalent Hemodialysis Patients in the United States: A National Study

“…A patient-centered approach to preoperative planning and intraoperative plan modifications that take into account the likelihood of AVF success may have improved utility and outcomes. 41–43 …”

Vascular Access Choice in Incident Hemodialysis Patients

“…Previous studies have attempted to address similar questions about vascular access. 15,16 A 2012 decision analysis compared AV fistula use with AV graft use, finding that an AV fistula attempt strategy was more effective when the probability of AV fistula maturation was 36% or greater. 16 However, this study did not consider patient mortality, take into account 15 concluding that AV fistulas were superior to AV grafts, although the reported difference was less than the differences reported in Figure 3.…”

Effect of the time to intervention on the outcome of thrombosed dialysis access grafts managed percutaneously

“…Patent hemodialysis access is critical for the survival of patients who rely on regularly scheduled hemodialysis, and a loss of patency results in under-dialysis, leading to higher morbidity and mortality (21). Percutaneous endovascular techniques have proven to be successful with the added benefits of lower cost and periprocedural morbidity when compared to surgical thrombectomy (3,11).…”