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Upper Extremity Arteriovenous Grafts Are Less Likely To Be Abandoned Compared To Autogenous Fistulas Despite A Higher Reintervention Rate
Nyah Patel, MPH1, Alik Farber, MD, MBA
1, Elizabeth King, MD
1, Mahmoud Malas, MD, MHS
2, Vipul Chitalia, MD, PhD
1, Jesse Columbo, MD
3, Phillip Goodney, MD
3, Jeffrey Siracuse, MD, MBA
1.
1Boston University, Boston, MA, USA,
2University of Californa San Diego, San Diego, CA, USA,
3Dartmouth Hitchcock Medical Center, Lebanon, NH, USA.
Objective: Upper-extremity arteriovenous (AV) accesses often require re-intervention. However, the frequency of multiple re-interventions and subsequent access failure is not well-characterized. Our goal was to evaluate the long-term re-interventions, risk-factors, and outcomes after AV access creation.
Methods: We performed a retrospective review of index upper extremity AV access creations (2017-2019) within the VQI Medicare linked VISION dataset for patients on dialysis. Re-interventions were defined as open or endovascular procedures on the access occurring 1 day or more after access creation. Access abandonment was defined as any new access creation, peritoneal dialysis, kidney transplant, or mortality following index access creation. Univariable, multivariable, Kaplan Meier, and Cox regression analyses were performed.
Results: There were 2551 patients evaluated with an index AV fistula (AVF) (80.5%) or AV graft (AVG) (19.5%). Patients undergoing AVG were more likely older, female sex, non-White race, non-ambulatory, not living at home, and have an inpatient procedure (P<.05). Re-intervention rates were 1.17/person-year for AVF, and 1.64/person-year for AVG. Within the first year, total re-interventions were 0 (36%), 1 (29.5%), 2 (15.4%), ≥3 (19.1%). On Kaplan-Meier analysis, freedom from new AV access creation at 3 years was 78% for AVF and 72% for AVG (P<.001). Freedom from TDC placement at 3 years was 71% for AVF and 66% for AVG (P=.19).
On multivariable analysis, AVG was independently associated with an increased risk of any re-intervention compared to AVF (RR 1.40 95% CI 1.3-1.6; P = <.0001). TDC placement
was increasingly associated each subsequent reintervention but did not vary by access type (Table). There was an elevated risk of access abandonment with each subsequent reintervention reinterventions, however access abandonment was lower with an AVG compared to an AVF (Table).
Conclusions: Access creation
reinterventions are common; more than 60% of patients required at least one procedure within the first year of access placement. Patients with AVG require more reinterventions, however have a lower rate of long-term access abandonment. Multiple endovascular re-interventions increase the risk of TDC placement within 2 years.
| | | | | | |
| Table: Multivariable analyses for TDC placement and access abandonment within 3 years |
| TDC Placement | Access Abandonment |
| Covariate | HR | 95% CI | P-value | HR | 95% CI | P-value |
| Re-interventions | | | | | | |
| None | Ref | Ref | | Ref | Ref | |
| 1 | 1.57 | 1.21-2.03 | .0007 | 1.55 | 1.32-1.82 | <.0001 |
| 2 | 2.75 | 1.99-3.79 | <.0001 | 2.02 | 1.63-2.51 | <.0001 |
| 3 | 4.08 | 2.78-6 | <.0001 | 2.52 | 1.92-3.32 | <.0001 |
| 4 or more | 5.69 | 3.89-8.31 | <.0001 | 2.28 | 1.71-3.06 | <.0001 |
| Access Type | | | | | | |
| AVF | Ref | Ref | | Ref | Ref | |
| AVG | 1.14 | .91-1.43 | .26 | 0.82 | .7-.96 | .015 |
| Abbreviations: Ref – reference; CI – confidence interval, HR – hazard ratio, AVF- arteriovenous fistula; AVG- arteriovenous graft |
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