E. Benrashid1, L. M. Youngwirth1, J. Kim1, D. N. Ranney1, J. C. Otto1, J. F. Lucas2, J. H. Lawson1 1Duke University Medical Center,Division Of Vascular Surgery, Department Of Surgery,Durham, NC, USA 2Greenwood Leflore Hospital,Greenwood, MS, USA
Introduction:
Current guidelines encourage early hemodialysis (HD) access placement in the chronic kidney disease (CKD) and end stage renal disease (ESRD) population. A variety of patient and operative factors (i.e. preoperative target vein diameter) have been proposed as predictors for access success or failure, although the current literature is conflicting. The objective of this study was to determine whether there were any predictors for HD access failure in this population.
Methods:
The Society for Vascular Surgery Vascular Quality Initiative database was queried to identify all new HD access cases performed by a single surgeon from January 2011 – December 2013. The primary outcome of interest was access failure as defined at follow-up. Secondary outcomes included necessity for access revision via surgical or interventional (percutaneous) techniques. Multivariable logistic regression was used to determine factors associated with access failure and need for revision. Age, gender, race, smoking status, diabetes, BMI ≥ 30, presence of a central venous catheter, dialysis status, and access type were included in the model.
Results:
During the study period, 1,354 HD access cases were performed, with n = 1,238 (91.4%) of these autogenous arteriovenous fistulae (AVF), and the remainder prosthetic (n = 57; 4.2%) or biologic (n = 59, 4.4%) arteriovenous grafts (AVG). Overall mean age was 56.6 ± 14.3 years, black race was 77.0%, and male gender was 48.2%, which was not significantly different among the groups. The total proportion of patients actively on dialysis was 66.7%, which differed significantly amongst the three access types (p < 0.001). On multivariable logistic regression analysis, active dialysis status was associated with a significantly higher probability of access failure [adjusted odds ratio (AOR), (95% confidence interval [CI]): 1.91 (1.17, 3.11); p = 0.010]. Additionally, the presence of a biologic AVG was associated with a significantly higher probably for the need for access revision [AOR (95% CI): 2.26 (1.32, 3.86); p = 0.003].
Conclusions:
Active dialysis status is associated with a higher incidence of access failure, with biologic AVG in particular associated with a greater need for revision. This data suggests that patients with CKD who are ‘pre-dialysis,’ in which there is any suspicion for progression to ESRD requiring renal replacement therapy (RRT), should receive more aggressive surgical referral and proactive placement of AVF prior to initiating any form of RRT. Additionally, given the > 2X likelihood for reintervention, patients that receive biologic AVG may be better suited with other access modalities. However, this cohort in particular may have specific anatomical limitations or have expended other access options, which may preclude AVF creation or the use of more conventional synthetic graft materials.