SCVS - Improved Maturation Of Two-stage Over One-stage Basilic Vein Transposition: A Multivariate Model

Back to 2025 Karmody Posters

Improved Maturation Of Two-stage Over One-stage Basilic Vein Transposition: A Multivariate Model
Max Zhu, MD, Joel Kruger, MD, Josh Geiger, MD, MS, Jose Aldana, MD, Adam Doyle, MD, Doran S. Mix, MD, Michael C. Stoner, MD, Karina A. Newhall, MD, MS.
University of Rochester Medical Center, ROCHESTER, NY, USA.

Objectives: Brachio-basilic arteriovenous fistula (BBAVF) creation can be performed in one or two stages. Available evidence does not suggest clear superiority of one approach. We hypothesize that individual surgeon practice patterns impact the choice of surgical approach for one- or two-stage fistula creation via basilic vein transposition. This study was designed to compare one- or two-stage BBAVF maturation, accounting for surgeon practice patterns.
Methods: We performed a retrospective study using the Vascular Quality Initiative (VQI) national hemodialysis access module from 2011-2022, including patients who underwent a first-time BBAVF procedure and had at least four weeks of follow-up data. Primary outcome was fistula maturation at last follow-up. We used multivariate logistic regression modeling to examine the association of surgical technique to fistula maturation and then performed multi-level modeling clustering by surgeon effects. We then analyzed a secondary outcome of 1-year reintervention using Cox proportional hazards modeling, again using single- and multi-level modeling techniques.
Results: A total of 6,348 patients underwent first-time BBAVF creation during the study period: 634 (10%) had 1-stage procedures, and 5,714 (90%) had 2-stage procedures. On univariate analysis, patients with 2-stage fistulas had higher rates of fistula maturation at last follow-up (63.2% vs. 43.1%, p<0.001) but also had higher rates of 1-year reintervention (37.0% vs. 30.4%, p=0.002). On multivariate analysis with multi-level modeling for surgeon random effects, adjusting for demographics, comorbidities, and patient anatomy (Table 1), 2-stage procedures were associated with higher rates of maturation (OR 2.3, 95%CI 1.9-2.9, p<0.001) and were associated with lower rates of 1-year reintervention on time-to-event analysis (HR 0.73, 95%CI 0.61-0.87, p<0.001). Clustering by surgeon random effects significantly improved the model fit for maturation rate (Likelihood-ratio 57.0, p<0.001) and 1-year reintervention (Likelihood-ratio 82.6, p<0.001).
Conclusions: Two-stage BBAVF creation was associated with superior overall maturation and decreased 1-year reintervention, even when adjustment was made for surgeon practice patterns. This study suggests that surgeon practice patterns play a significant role in selecting surgical techniques and the resulting long-term outcomes, and it should be considered in further comparative analyses.

Select univariate and multivariate outcomes of fistula maturation
Covariate	Univariate OR	95% CI	P	Single-level Multivariate OR	95% CI	P	Multi-level Multivariate OR	95% CI	P
2-Stage Procedure	2.3	1.9-2.7	<0.001	2.3	1.9-2.8	<0.001	2.3	1.9-2.9	<0.001
Age (years)	1.0	0.99-1.0	0.019	0.99	0.99-1.0	0.001	0.99	0.98-1.0	<0.001
Female sex	0.71	0.63-0.80	<0.001	0.74	0.65-0.85	<0.001	0.73	0.63-0.84	<0.001
Black race (ref. White)	0.82	0.72-0.93	0.002	0.77	0.66-0.89	0.001	0.81	0.68-0.96	0.014
ADI percentile 81-100 (ref. 1-20)	0.61	0.50-0.75	<0.001	0.69	0.54-0.88	0.003	0.82	0.61-1.1	0.201
BMI (kg/m²)	0.98	0.98-0.99	<0.001	0.99	0.98-0.99	0.002	0.98	0.97-0.99	0.002
Insulin-dependent diabetes (ref. No diabetes)	1.1	0.97-1.3	0.144	1.2	1.0-1.4	0.017	1.2	1.0-1.4	0.029
CKD stage ≤3 (ref. stage 4 or 5)	1.7	1.1-2.7	0.012	1.9	1.2-3.1	0.007	2.0	1.2-3.3	0.007
Vein Diameter (mm)	1.1	1.0-1.1	0.016	1.1	1.0-1.1	0.031	1.1	1.0-1.1	0.017

Back to 2025 Karmody Posters