Comparison of Post-Creation Procedures and Costs between Surgical and an Endovascular Approach to Arteriovenous Fistula Creation

Abstract

additional procedures to facilitate maturation and maintain function after the initial AVF creation (3, 4). Despite these procedures, a substantial proportion of AVFs never become usable for hemodialysis, leaving the patient dependent on temporary central venous catheters (CVCs) for an extended time before another arteriovenous access (prosthetic arteriovenous graft [AVG]) or a new surgical AVF [SAVF]) can be created and used (5, 6). Such catheter dependence can lead to complications, such as infection. Importantly, AVFs that require facilitative procedures for maturation have poorer durability than those that do not (7, 8). A new endovascular catheter-based system the everlinQ endoAVF System, has been developed that uses a minimally invasive method to create an AVF (endoAVF) as an alternative to the traditional open surgical approach (9, 10). The everlinQ endoAVF system creates a side-to-side anastomosis without open surgery or vessel dissection, minimizing trauma to the vessels. A prospective clinical study, the Novel Endovascular

Comparison between Surgical and Endovascular Hemodialysis Arteriovenous Fistula Interventions and Associated Costs

“…The results of this study are consistent with findings in Yang et al's study (9), demonstrating lower post-AVF creation intervention rates and costs for the endoAVF versus the SAVF cohort. However, our results are perhaps more illuminating, owing to the more comprehensive ESKD patient sample available in the present analysis versus the 5% sample used by Yang et al, the ability to analyze incident and prevalent cohorts separately with the use of USRDS, inclusion of BMI in the PS matching, and the use of national Medicare payment rates as the basis for determining costs because the payment rates are consistent across the country and for every hospital.…”

“…However, studies have found that 70%-86% of SAVFs require 2-3 interventions per patient-year (PY) in the first year after fistula creation to facilitate maturation and maintain function after fistula creation (6)(7)(8)(9)(10). SAVFs that are not usable for dialysis or have shortened survival leave the patient dependent on CVCs.…”

“…Creating a fistula with the use of an endovascular approach may reduce neointimal hyperplasia and stenosis by minimizing trauma to the vessels and by the use of a side-to-side anastomosis. A recent study by Yang et al compared AVF interventions to achieve maturation and maintain vascular access and their associated costs in patients with a new endoAVF versus SAVF patients from a 5% random sample from Medicare Standard Analytical Files (SAFs) (9). However, information on incident and prevalent status and patient body mass index (BMI), which may affect the rate and type of interventions, could not be assessed with the use of Medicare SAFs.…”

Endovascular Proximal Forearm Arteriovenous Fistula for Hemodialysis Access: Results of the Prospective, Multicenter Novel Endovascular Access Trial (NEAT)

“…The rate of interventions for endoAVFs was 0.46/patientyear and lower than that of surgical AVFs. 41 Surgical AVFs often require 2 to 3 interventions to facilitate maturation. 15,42 The ability to achieve functional usability equivalent to surgical AVFs with fewer interventions and fewer days of catheter exposure is a substantial clinical benefit for patients.…”

Place of Percutaneous Fistula Devices in Contemporary Management of Vascular Access

“…Overall, percutaneous AVF outcomes look encouraging and appear to result in improved primary patency, as well as lower associated first-year costs compared with surgically created AVFs (9). They confer the advantage of eliminating surgical variation in outcomes, and offer select patients with suitable anatomy a less invasive option and the avoidance of general anesthesia, utilized for more complex surgical AVF procedures.…”