Thigh Grafts Contribute Significantly to Patients' Time on Dialysis

Abstract

Background and objectives: Thigh grafts are placed in hemodialysis patients who have exhausted all arm access sites. The goal of this study was to compare the survival, complication rates, and overall contribution of thigh grafts with arm grafts and fistulas in patients with at least one functional thigh graft during their dialysis history.Design, setting, participants, & measurements: This longitudinal review of a prospectively acquired clinical database included 85 thigh graft recipients. The rates of survival, thrombosis, infection, and other complications were determined for a total of 268 fistulas, arm grafts, and thigh grafts placed in these patients.Results: In this patient subset, thigh graft primary failure rate was lower than arm grafts and fistulas (3 versus 13 and 61%, respectively). Excluding primary failures, thigh grafts survived longer than both arm grafts and mature fistulas (53 versus 14 and 32%, at 3 years; 47 versus 3 and 11% at 5 years). Thigh grafts had a lower thrombosis rate than arm grafts (0.543 versus 1.457/patient-year) but similar rates of loss as a result of infection and surgical revision. In patients with previous arm accesses, thigh grafts contributed 51% of total dialysis time compared with 38 and 11% for arm grafts and fistulas.Conclusions: Thigh grafts provide long-term, thrombosis-and infection-free dialysis access for patients with exhausted arm access sites. The decision for thigh graft placement should, therefore, be made as soon as there is evidence for unavailability of arm access sites so that catheter use can be minimized.

Long-term Outcomes of Arteriovenous Thigh Grafts in Hemodialysis Patients

“…This rate is similar to the 3%-8.1% rates reported by two other studies (11,13). We have previously noted a higher technical failure rate in thigh grafts than in upper-extremity grafts (5), whereas another group reported a lower rate in thigh grafts (13).…”

“…These findings closely agree with those of three large series (.100 thigh grafts) that reported secondary graft survival rates of 68%-78% at 1 year, 54%-64% at 2 years, and 46%-51% at 5 years (Table 5). In fact, two prior observational studies observed secondary survival of thigh grafts to be similar or superior to that obtained with upper-extremity grafts (5,13). Moreover, as our study demonstrated, thigh graft survival is far superior to that obtained with tunneled dialysis catheters.…”

“…Most infected grafts required surgical excision, although a few were salvaged by removal of the infected graft segment and placement of a new jump graft. Some studies have reported a higher likelihood of infection in thigh grafts than upper-extremity grafts (5,20), whereas another showed similar rates (13). However, the cumulative risk of dialysis catheter-related bacteremia at 1 year was 79%, which was considerably higher than the 21% rate of thigh graft infection.…”

“…Most published studies reported the outcomes of relatively few thigh grafts, with inconsistent definitions of graft outcomes (3)(4)(5)(6)(7)(8)(9)(10)(11). Three larger series (.100 thigh grafts) (12)(13)(14) provided information about graft outcomes using standardized definitions (15) but did not comprehensively analyze clinical factors or comorbid conditions that are associated with thigh graft outcomes. Finally, none of the published reports directly compared the outcomes of thigh grafts and tunneled dialysis catheters.…”

Lower Extremity Permanent Dialysis Vascular Access

“…Geenen et al (28) reported a 27% infection rate in the largest reported series of 153 LE-AVGs. In a longitudinal follow-up of 268 accesses over 8 years, Ram et al (21) reported that thigh AVGs survived longer than upper arm AVGs and upper arm AVFs (47% versus 11% and 3% at 5 years, respectively; P,0.01), adding significant survival time on dialysis and longevity for these patients.…”