Body Mass Index Affects Upper Extremity Arteriovenous Access Outcomes
Stephen J. Raulli, M.Phil.1, Kristiana Sather, M.D.1, Quinten Dicken1, Alik Farber, M.D., M.B.A1, Douglas W. Jones, M.D.1, Jeffrey A. Kalish, M.D.1, Mohammad Eslami, M.D.2, Yixin Zhang1, Jeffrey J. Siracuse, M.D.1.
1Boston University, Boston, MA, USA, 2UPMC, Pittsburgh, PA, USA.
Objectives: A patient’s obesity status can affect both peri- and postoperative outcomes. Given that obesity and end stage renal disease are growing in prevalence, we sought to assess how body mass index (BMI) affects results of upper extremity arteriovenous (AV) access.
Methods: A retrospective single institution review was performed from 2014-2018. Patient, demographics, comorbidities, AV access details were recorded. BMI categories were defined as underweight (UW) (<18.5), normal weight (NW) (18.5-24.9), overweight (OW) (25-29.9), obese class I (OBI) (30-34.9), obese class II (OBII) (35-39.9), morbidly obese (MO) (>40). Perioperative complications and long-term outcomes including access maturation (as assessed by access being used or surgeon judgement if not on dialysis), occlusion, and re-intervention were evaluated.
Results: 620 cases were performed on patients who were UW (1.5%) NW (29.2%) OW (30.1%), OBI (20.3%), OBII (8.9%), and MO (9.4%). Access type included brachiocephalic (43.1%), brachiobasilic (25.3%), and radiocephalic (14.2%) fistulas, as well as AV grafts (14.5%). Average age was 59.6 and 59.9% were male. Univariable analysis showed no difference in perioperative wound, hematoma, home discharge, and early patency. On multivariable analysis, non-maturation within 180 days was associated with OW (OR 1.92, 95% CI 1.14-3.3, P=.002), OBII (OR 2.08, 95% CI 1.15-3.7, P=.01), and MO (OR 3.7, 95% CI 1.85 - 7.1, P<.001). AV access reintervention was associated with OW (HR 1.83, 95% CI 1.34-2.50), OBII (HR 1.89, 95% CI 1.21-2.95), MO (HR 1.69, 95% CI 1.11-2.59) (P=.002). BMI was not independently associated with steal, readmission, or survival. Freedom from reintervention at 2 years on Kaplan-Meier analysis differed by BMI (UW 55%, 56% NW, 38% OW, 49% OBI, 47% OBII, 46% MO, P=.04). There was no difference in freedom from occlusion or survival.
Conclusions: Obesity is associated with higher rates of non-maturation and reintervention. Surgeons performing access on obese patients need to consider this for planning and, setting expectations. Weight loss assistance may need to be incorporated into treatment algorithms.
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