Objectives
Access-related hand ischemia (ARHI) is a major complication after hemodialysis access construction. This study was designed to prospectively describe its incidence, predictors, interventions and associated access maturation.
Methods
The Hemodialysis Fistula Maturation Study is a multicenter prospective cohort study designed to identify predictors of autogenous arteriovenous access (AVF) maturation. Symptoms and interventions for ARHI were documented and participants who received interventions for ARHI were compared to other participants using a nested case-control design. Associations of ARHI with clinical, ultrasound, vascular function, and vein histological variables were each individually evaluated using conditional logistic regression and the association with maturation assessed by relative risk, Pearson's chi-square test, and multiple logistic regression.
Results
The study cohort included 602 participants with median follow-up 2.1 years (10th - 90th percentiles: 0.7 - 3.5 yrs). Mean age was 55.1 ± 13.4 (SD) years and the majority were male (70%), Caucasian (47%), diabetic (59%), smokers (55%), on dialysis (64%), and underwent an upper arm AVF (76%). Symptoms of ARHI occurred in 45 (7%) participants and intervention was required in 26 (4%). Interventions included distal revascularization with interval ligation (13), ligation (7), banding (4), revision using distal inflow (1), and proximalization of arterial inflow (1). Interventions were performed ≤ 7 days after AVF creation in 4 participants (15%), between 8 - 30 days in 6 (23%) and > 30 days in 16 (63%). Female gender (OR 3.17: 95% CI 1.27 - 7.91, p = 0.013), diabetes (13.62: 1.81 - 102.4, p = 0.011), coronary artery disease (2.60: 1.03 - 6.58, p = 0.044), higher pre-operative venous capacitance (per % /10mmHg: 2.76: 1.07 - 6.52, p = 0.021) and maximum venous outflow slope (per (mL/100 mL/min) /10 mmHg: 1.13: 1.03 - 1.25, p = 0.011) were significantly associated with interventions, while a lower carotid-femoral pulse-wave velocity and the outflow vein diameter in the early postoperative period (days 0 - 3) approached significance (p < .10). Intervention for ARHI was not associated with AVF maturation failure (unadjusted risk ratio 1.18: 0.69 - 2.04, p = 0.56, adjusted odds ratio 0.97: 0.41 - 2.31, p = 0.95).
Conclusions
Remedial intervention for ARHI after AVF construction is uncommon. Diabetes, female gender, capacitant outflow veins and coronary artery disease are all associated with an increased risk of intervention. These higher risk patients should be counseled preoperatively, their operative plans designed to reduce the risk of hand ischemia, and followed closely.