Decreased Cumulative Access Survival in Arteriovenous Fistulas Requiring Interventions to Promote Maturation

Abstract

SummaryBackground and objectives New arteriovenous fistulas (AVF) are frequently unsuitable for hemodialysis because of AVF nonmaturation. Aggressive endovascular or surgical interventions are often undertaken to salvage nonmaturing AVFs. The effect of early interventions to promote AVF maturation on subsequent long-term AVF outcomes is unknown.Design, setting, participants, & measurements We evaluated 173 hemodialysis patients from two academic centers who received a new AVF. Of these, 96 (56%) required no further intervention, 54 (31%) required one intervention, and 23 (13%) required two or more interventions to achieve suitability for dialysis. We calculated AVF survival and frequency of postmaturation interventions in each group.Results Cumulative AVF survival (access cannulation to permanent failure) in patients with two or more versus one versus zero interventions before maturation was 68% versus 78% versus 92% at 1 year, 57% versus 71% versus 85% at 2 years, and 42% versus 57% versus 75% at 3 years. Using Cox regression analysis with interventions before maturation, age, sex, race, diabetes, peripheral vascular disease, access site, and obesity in the model, intervention before maturation (two or more) was the only factor associated with cumulative AVF survival. The number of interventions required to maintain patency after maturation was 3.51 Ϯ 2.20 versus 1.37 Ϯ 0.31 versus 0.76 Ϯ 0.10 per year in patients with two or more versus one versus zero interventions before maturation. ConclusionsCompared with AVF that mature without interventions, AVF that require interventions have decreased cumulative survival and require more interventions to maintain their patency for hemodialysis.

New Insights into Dialysis Vascular Access: What Is the Optimal Vascular Access Type and Timing of Access Creation in CKD and Dialysis Patients?

“…Studies have shown prolonged maturation times in patients with diabetes (31) and decreased primary and secondary patency (32). However, other studies have also shown no association between diabetes and time to maturation (33), risk of nonmaturation (34,35), or patency (36). Even in a well validated prediction model (37), no association between diabetes and risk of nonmaturation was found (27).…”

Predictive Parameters of Arteriovenous Fistula Functional Maturation in a Population of Patients with End-stage Renal Disease

“…A combination of female gender and increased age (> 65) has been shown to be significantly associated with non-maturation when compared to men of the same age group [22,24]. However, several other studies found no significant association between female gender and high risk of AVF non-maturation [22,25,27].…”

Should Buttonhole Cannulation Be Discontinued?

“…The rate of systemic fistula infections is more difficult to interpret because events rates were low and results were not reported as per 1000 fistula-days, with different reporting periods: 2003 to mid-2004 for RLC and 2004-2009 for BHC. In addition, interpretation of the rate of fistula loss and need for surgical intervention is hampered by the exclusion of radiologic interventions that represent the majority of interventions in patients with fistula and have been significantly associated with fistula patency outcomes (21). The utilizationrelated outcomes were as follows: Training time and ongoing support encounters were significantly higher with BHC (median, 46 days [interquartile range, 37-60 days] versus 37 days [interquartile range, 25-58 days] in the RLC and 1 encounter per 13.2 fistula-days versus 1 encounter per 19 fistula-days for RLC).…”