Upper Extremity Arteriovenous Grafts are Less likely to be Abandoned Compared to Autogenous Fistulas Despite a Higher Reintervention Rate.

OBJECTIVE

Upper-extremity arteriovenous (AV) access often requires re-intervention. However, the frequency of re-interventions and subsequent access failure is not well-characterized. Our goal was to evaluate the frequency and type of 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 Vascular Implant Surveillance and Interventional Outcomes Network dataset for patients on hemodialysis. 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 death following index access creation. Univariable, multivariable, Kaplan Meier, and Cox regression analyses were performed.

RESULTS

There were 2,551 patients with an index AV graft (AVG) (19.5%) or AV fistula (AVF) (80.5%). Patients who underwent an AVG were more likely older, female sex, of non-White race, non-ambulatory, not living at home, and to undergo the procedure as an inpatient (P<.05). Re-intervention rates were 1.64/person-year for AVG and 1.17/person-year for AVF. On Kaplan-Meier analysis, freedom from new AV access creation at 3 years was 72% for AVG and 78% for AVF (P<.001). Freedom from tunneled dialysis catheter (TDC) placement at 3 years was 66% for AVG and 71% for AVF (P=.19). On multivariable analysis, undergoing placement of an 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 = <.001). TDC placement was increasingly associated with each subsequent reintervention, but did not vary by access type. There was an elevated risk of access abandonment with subsequent reinterventions; however, long-term access abandonment was lower with an AVG compared to an AVF (RR 0.82 95% CI 0.7-.96; P = .015).

CONCLUSIONS

Re-interventions to support hemodialysis access are common, and more than 60% of patients required at least one procedure within the first year of access placement. While patients with AVG require more re-interventions, they also have a lower rate of long-term access abandonment and similar rates of TDC placement compared to patients who receive an AVF.