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Objective: The increasing age of patients requiring renal replacement therapy (RRT) presents continuing challenges for the access surgeon. Strategic planning of vascular access, particularly in the octogenarians, is critical for successful treatment of individuals with reduced life expectancy. We undertook a retrospective analysis to determine if Fistula First is, indeed, the best approach for patients in their ninth decade of life.
Methods: All patients receiving an extremity hemodialysis access during the study period (2012 to 2015) over the age of 80 years were reviewed. Only patients with a follow-up visit were included in the assessment. Successful access creation was characterized by the ability of the hemodialysis center to cannulate the access or, for patients whose RRT had not yet begun, the approval for cannulation by the surgeon was accepted. The time from access creation until use or approval, time until first intervention, and patency were recorded. A control group was comprised of the first 30 fistulae created in 2014 for patients younger than 60 years.
Results: 134 accesses (56 Arteriovenous Grafts [AVG] and 78 Arteriovenous fistulae [AVF]) were created in 117 patients over the age of 80 years. 52 AVG (93%) and 64 AVF (82%; p=ns) were available for longitudinal follow-up and constitute the study group. Octogenarians with an AVF had a mean ± SD cannulation time of 97± 60 days and an AVG of 41 ± 39 days respectively (t=4.93; p < .0001.) The control group could be cannulated at 82 ± 35 days. The time to the first intervention in the octogenarians were AVF 356 ±508 days; AVG 121 ± 102 (t=2.11; p=.04.) Secondary patency was similar in the two groups at one year (85%).
Conclusions: We now favor the utilization of AV grafts in elderly patients. It has allowed a significant reduction in catheter days and reduced returns to the operating theater for access revision. The need for more frequent percutaneous intervention is apparent but it is a small price to pay for reduced catheter days and similar longevity for the access. Given the overall reduction in life expectancy without a significant improvement in outcome for AVF, we believe that the use of AVG in the octogenarian should be the preferred access option.