Vascular Access Placement Order and Outcomes in Hemodialysis Patients: A Longitudinal Study

Abstract

Background: Arteriovenous accesses (AVA) in patients performing hemodialysis (HD) are labeled “permanent” for AV fistulas (AVF) or grafts (AVG) and “temporary” for tunneled central venous catheters (TCVC). Durability and outcomes of permanent vascular accesses based on the sequence in which they were placed or used receives little attention. This study analyzed longitudinal transitions between TCVC-based and AVA-based HD outcomes according to the order of placement. Methods: All 391 patients initiating chronic HD via a TCVC between 2012 and 2013 at 12 outpatient academic dialysis units were included in this study. Chronological distributions of HD vascular accesses were recorded over a mean (SD) of 2.8 (0.9) years and sequentially grouped into periods for TCVC-delivered and AVA-delivered (AVF or AVG) HD. Primary AVA failure and cumulative access survival were evaluated based on access placement sequence and type, adjusting for age. Results: In total, 92.3% (361/391) of patients underwent 497 AVA placement surgeries. Analyzing the initial 3 surgeries, primary AVF failure rates increased with each successive fistula placement (p = 0.008). Among the 82.9% (324/391) of TCVC patients successfully converted to an AVA, 30.9% returned to a TCVC, followed by a 58.0% conversion rate to another AVA. Annual per-patient vascular access transition rates were 2.02 (0.09) HD periods using a TCVC and 0.54 (0.03) HD periods using an AVA. Comparing the first AVA used with the second, cumulative access survivals were 701.0 (370.0) vs. 426.5 (275.0) days, respectively. Excluding those never converting to an AVF or AVG, 169 (52.2%) subsequently converted from a TCVC to a permanent access and received HD via AVA for ≥80% of treatments. Conclusions: HD vascular access outcomes differ based on the sequence of placement. In spite of frequent AVA placements, only half of patients effectively achieved a “permanent” vascular access and used an AVA for the majority of HD treatments.

A randomized pilot study comparing graft-first to fistula-first strategies in older patients with incident end-stage kidney disease: Clinical rationale and study design

“…This exposes older patients to time-consuming procedures that may negatively affect upper extremity strength and erode quality of life. Prosthetic AVGs have nearly double primary patency rates (80–90% vs. 40–60%) and three times shorter intervals to cannulation (44 vs. 97 days) than native AVFs [ [19] , [20] , [21] ]. These properties may render AVGs as a superior “catheter-sparing” strategy compared to AVFs.…”

Vascular access for hemodialysis: A perpetual challenge

“…48 In a recent study, we analyzed longitudinal transitions between catheter-based and arteriovenous access-based angioaccess outcomes in 391 patients initiating chronic hemodialysis with a tunneled central venous catheter between 2012 and 2013 and calculated the proportion of dialysis sessions delivered via an arteriovenous access across all hemodialysis sessions observed. 49 After a mean follow-up period of 2.8 years, 83% of the patients converted from using a catheter to arteriovenous access; of these, 31% returned to using a catheter followed by a 58% re-conversion rate to using an arteriovenous access. Annual per-patient vascular access transition rates were 2.02 (SD 0.09) hemodialysis periods using a catheter and 0.54 (SD 0.03) hemodialysis periods using an arteriovenous access.…”

“…Of patients who initiated hemodialysis with a central venous catheter, 45% converted to using an arteriovenous access (median time to conversion 66‐105 days); of these, 30% converted back to a catheter (median time to conversion 58‐70 days) . In a recent study, we analyzed longitudinal transitions between catheter‐based and arteriovenous access‐based angioaccess outcomes in 391 patients initiating chronic hemodialysis with a tunneled central venous catheter between 2012 and 2013 and calculated the proportion of dialysis sessions delivered via an arteriovenous access across all hemodialysis sessions observed . After a mean follow‐up period of 2.8 years, 83% of the patients converted from using a catheter to arteriovenous access; of these, 31% returned to using a catheter followed by a 58% re‐conversion rate to using an arteriovenous access.…”

“…Annual per‐patient vascular access transition rates were 2.02 (SD 0.09) hemodialysis periods using a catheter and 0.54 (SD 0.03) hemodialysis periods using an arteriovenous access. Overall, of the patients who converted from catheter‐based to arteriovenous access‐based hemodialysis, only 52% received dialysis via the arteriovenous access for ≥80% of dialysis treatments . Another study, done in Canada, evaluated 1091 patients initiated on hemodialysis between 2004 and 2012 who received at least one arteriovenous fistula creation attempt .…”

“…Overall, of the patients who converted from catheter-based to arteriovenous access-based hemodialysis, only 52% received dialysis via the arteriovenous access for ≥80% of dialysis treatments. 49 Another study, done in Canada, evaluated 1091 patients initiated on hemodialysis between 2004 and 2012 who received at least one arteriovenous fistula creation attempt. 50 During the first year following hemodialysis initiation, catheterfree fistula use for ≥90% of hemodialysis treatments was achieved in only 31% of patients who received one arteriovenous fistula and 11% of patients who received two fistulas.…”