Society For Clinical Vascular Surgery

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Role of Antiplatelet Therapy in the Durability of Hemodialysis Access
Satinderjit Locham, MD, Robert J. Beaulieu, MD, Hanaa Dakour Aridi, MD, Besma Nejim, MBChB, MPH, Mahmoud Malas, MD, MHS.
Johns Hopkins Medical Institution, Baltimore, MD, USA.

OBJECTIVES: Vascular access failure is a common complication among patients undergoing hemodialysis (HD). Anti-platelet therapy (APT) is commonly prescribed to improve vascular access patency. The purpose of this study is to assess the role of APT in the durability of arteriovenous fistula (AVF) and grafts (AVG).
METHODS: All patients undergoing HD access in the VQI database (2011-2017) were included and divided into 2 groups: no antiplatelet therapy (NAPT) versus any APT (Aspirin or P2Y12 inhibitors [PI]) prescribed at discharge. Univariate and multivariate (cox regression) analyses were used to evaluate primary patency (PP) at 18 months.
RESULTS: A total of 23,284 patients undergoing HD access were identified (4,999 AVG and 18,285 AVF). APT was noted among 49 % and 46% of AVG and AVF patients, respectively. Compared to patients with NAPT, patients on APT were older (AVG: 65 vs. 61; AVF: 64 vs. 57 years) and had more comorbidities including hypertension (AVG: 94% vs. 93%; AVF: 96% vs. 93%), diabetes (AVG: 65% vs. 53%; AVF: 67% vs. 52%), CHF (AVG: 32% vs. 23%; AVF: 31% vs. 20%) and PAD (AVG: 11% vs. 7%; AVF: 9% vs. 5%) (All P<0.001). 30-day mortality (1.6 vs. 1.7% and 0.9% vs. 0.8%) and in-hospital bleeding (2.4% vs. 1.9% and 1.9% vs. 1.5%) were similar between both groups in AVG and AVF, respectively (P>0.05). In patients undergoing AVF, PP was also similar between APT and NAPT (figure). However, in patients undergoing AVG, PP rates were higher for APT [aspirin alone (41% vs. 35%) and PI alone (49% vs. 35%)] versus NAPT (P=0.02). After adjusting, cox-regression analysis showed 15% decreased risk of loss of PP in AVG patients on aspirin alone versus NAPT [HR (95%CI):0.85(0.73-0.99), P=0.03]. However, no difference was seen in AVG patients on PI alone versus NAPT [HR (95%CI): 0.77(0.55-1.09), P=0.14].
CONCLUSIONS: Using a large national database, we showed APT in patients undergoing AVF is not associated with improved access durability. However in AVG, aspirin use demonstrated improved patency rates. No significant difference was seen in patients on P2Y12 inhibitors compared to NAPT. Our study support the use of aspirin in patients undergoing AVG placement.

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