Division of Vascular and Endovascular Surgery, St. Louis University, St. Louis, MO.
Division of Vascular and Endovascular Surgery, Chobanian and Avedisian School of Medicine, Boston University, Boston, MA; Division of Vascular and Endovascular Surgery, Dartmouth Medical School, Lebanon, NH.
J Vasc Surg. 2024 Apr;79(4):925-930. doi: 10.1016/j.jvs.2023.12.031. Epub 2024 Jan 17.
Patients undergoing arteriovenous (AV) access creation for hemodialysis often have significant comorbidities. Our goal was to quantify the long-term survival and associated risks factors for long-term mortality in these patients to aid in optimization of goals and expectations.
The Vascular Implant Surveillance and Interventional Outcomes Network Vascular Quality Initiative Medicare linked data was used to assess long-term survival in the HD registry. Demographics, comorbidities, and interventions were recorded. Because the majority of hemodialysis patients are provided Medicare, Medicare linkage was used to obtain survival data. Multivariable analysis was used to identify independent associations with mortality.
There were 13,945 AV access patients analyzed including 10,872 (78%) AV fistulas and 3073 (22%) AV grafts. The median age was 67 years and 56% of patients were male. Approximately one-third had a prior AV access and 44.7% had prior tunneled dialysis catheters. Patients receiving an AV fistula, compared with AV grafts, were more often younger, male, White, obese, independently ambulatory, preoperatively living at home, and less often have a prior AV access and tunneled dialysis catheters (P < .05 for all). The 5-year mortality overall was 62.9% with 61.2% for AV fistulas and 68.8% for AV grafts (P < .001). On multivariable analysis for 5 year mortality, nonambulatory status (hazard ratio [HR], 1.67; 95% confidence interval [CI], 1.53-1.83; P < .001), lower extremity access (HR, 1.67; 95% CI, 1.35-2.05; P < .001), human immunodeficiency virus or acquired immunodeficiency syndrome (HR, 1.44; 95% CI, 1.13-1.82; P < .001), White race (HR, 1.43; 95% CI, 1.35-1.51; P < .001), congestive heart failure (HR, 1.33; 95% CI, 1.26-1.41; P < .001), chronic obstructive pulmonary disease (HR, 1.23; 95% CI, 1.15-1.31; P < .001), and AV graft placement (HR, 1.12; 95% CI, 1.02-1.23, P = .016) were most associated with poor survival. Factors associated with improved survival were never smoking (HR, .73; 95% CI, 0.67-0.79; P < .001), prior/quit smoking (HR, .78; 95% CI, 0.72-0.84; P < .001), preoperative home living (HR, .75; 95% CI, 0.68-0.83; P < .001), and hypertension (HR, .89; 95% CI, 0.8-0.99; P = .03).
Long-term survival in Medicare patients undergoing AV access creation is poor with nearly two-thirds of patients having died at 5 years. There are many modifiable risk factors that may improve survival in these patients and give an opportunity for transplantation.
接受动静脉（AV）通路创建以进行血液透析的患者通常存在重大合并症。我们的目标是量化这些患者的长期生存率和与长期死亡率相关的风险因素，以帮助优化目标和期望。
使用血管植入物监测和介入结果网络血管质量倡议医疗保险链接数据评估 HD 登记处的长期生存率。记录人口统计学、合并症和干预措施。由于大多数血液透析患者都提供医疗保险，因此使用医疗保险链接来获取生存数据。多变量分析用于确定与死亡率相关的独立关联。
共分析了 13945 例 AV 通路患者，包括 10872 例（78%）AV 瘘和 3073 例（22%）AV 移植物。中位年龄为 67 岁，56%的患者为男性。大约三分之一的患者有先前的 AV 通路，44.7%的患者有先前的隧道透析导管。与 AV 移植物相比，接受 AV 瘘的患者更年轻、更男性化、更白人、更肥胖、更独立活动、术前居住在家中、先前的 AV 通路和隧道透析导管较少（所有 P<0.05）。总体 5 年死亡率为 62.9%，AV 瘘为 61.2%，AV 移植物为 68.8%（P<0.001）。在多变量分析中，5 年死亡率的非活动状态（危险比[HR]，1.67；95%置信区间[CI]，1.53-1.83；P<0.001）、下肢通路（HR，1.67；95% CI，1.35-2.05；P<0.001）、人类免疫缺陷病毒或获得性免疫缺陷综合征（HR，1.44；95% CI，1.13-1.82；P<0.001）、白人种族（HR，1.43；95% CI，1.35-1.51；P<0.001）、充血性心力衰竭（HR，1.33；95% CI，1.26-1.41；P<0.001）、慢性阻塞性肺疾病（HR，1.23；95% CI，1.15-1.31；P<0.001）和 AV 移植物放置（HR，1.12；95% CI，1.02-1.23，P=0.016）与较差的生存最相关。与改善生存相关的因素包括从不吸烟（HR，0.73；95% CI，0.67-0.79；P<0.001）、既往/戒烟（HR，0.78；95% CI，0.72-0.84；P<0.001）、术前居家生活（HR，0.75；95% CI，0.68-0.83；P<0.001）和高血压（HR，0.89；95% CI，0.8-0.99；P=0.03）。
在接受 AV 通路创建的 Medicare 患者中，长期生存率较差，近三分之二的患者在 5 年内死亡。有许多可改变的风险因素可以改善这些患者的生存并为移植提供机会。
