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Five-year Comparison with Quality-of-Life Analysis of Proximal versus Distal Primary Non-synthetic Arterio Venous Fistula (AVF) for Longterm Venous Access in Patients on Haemodialysis (HD)
Nader Hamada, MB BCh MCh MRCS, Sherif Sultan, MD FACS FRCS EBQS-Vasc, Niamh Hynes, MD MRCS MMSc endo.
Western Vascular Institute, Galway, Ireland.

Introduction:
End Stage Renal Disease (ESRD) patients ideally should have Arterio-Venous Fistula (AVF) formation 3-6months prior to commencing Haemodialysis (HD). However this is not always possible with contemporary strained healthcare resources.
Objectives:
We aim to compare autologous Proximal AVF (PAVF) formation with Distal AVF (DAVF) in patients already on HD. Primary endpoints are 4-year primary and post-intervention patency. Secondary endpoints are freedom from major adverse clinical events (MACE), and Quality Time Spent without Symptoms of disease or Toxicity of Treatment (Q-TWIST)
Design:
Retrospective cohort study using data from a prospectively-maintained Vascular Database
Methods:
From January 2003 to June 2009, 179 patients with ESRD on HD had 200 procedures for AVF formation (37 DAVF vs. 163 PAVF), in arms in which no previous fistula had been formed. No synthetic graft was used.
Results:
4-year primary functional patency significantly improved with PAVF (68.9%+/-SD8.82%) compared to DAVF (7.25%+/-SD4.94%) (p<0.0001)
4-year secondary functional patency significantly improved with PAVF (76.02%+/-SD9.61%) versus DAVF (7.45%+/-SD5.07%, p<0.0001)
5-year freedom from MACE was 85% with PAVF compared to 40% with DAVF (P<.005)
5-year QTWiST significantly improved with PAVF compared to DAVF (P<0.005).
Conclusion:
PAVF bestows long-term functional access with fewer complications compared to DAVF and should be preferentially offered to patients already on HD.


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