Southern Association for Vascular surgery

October 17, 2008

Dialysis Access Outcomes in the Era of the Fistula First Initiative

Christopher Seaver*, Beverly Childress*, Thomas Huber, Scott Berceli
University of Florida, Gainesville, FL

INTRODUCTION: The Kidney Disease Outcome Quality (KDOQI) and Fistula First Initiatives have emphasized autogenous arteriovenous fistulae (AVF) as the primary choice for dialysis access. With an increasing emphasis on autogenous access, many surgeons have expanded their pre-operative criteria to meet this charge. While the superior patency of AVF is well established, aggressive use of marginal veins may result in high rates of non-maturation and inadvertent prolonged use of central venous catheters. These issues were explored using a prospectively maintained, comprehensive database of our dialysis access practice.
METHODS: Patients undergoing dialysis access placement at the Gainesville VA from October 2002 to September 2004 were prospectively enrolled to examine all aspects of their access care until termination of follow-up in September 2007. Preoperative vein mapping and physiologic arterial studies were used to determine optimum configurations, with veins greater than 3.0 mm considered acceptable for use. Prosthetic graft was used only in the absence of suitable vein. An aggressive approach to revision of non-maturing AVF was employed. AVG, prosthetic graft, and catheter usage, salvage procedures and complications were collected to create a detailed timeline of these events for each patient.
RESULTS: 26 patients had placement of 38 AVF and 8 prosthetic grafts as detailed in Table 1.

Table 1. Access Performance Measures
	AVF *(n=38)*	Prosthetic Grafts (n=8)
Suitable to initiate dialysis	26 (68%)	6 (75%)
Time from access placement to maturation / 1^st cannulation	249 ± 206 days	80 ± 56 days
Time from maturation / 1^st cannulation to failure	485 ± 424 days	201 ± 388 days
Time from 1^st access revision to failure	369 ± 361 days	188 ± 406 days
Revisions (per mature AVF / graft)	2.0	1.7
Diagnostic fistulograms without revision (per mature AVF / graft)	0.7	0.7
Complications (per AVF / graft)	2.0	2.0
- stenosis - thrombosis - infection - ischemia	1.3 0.4 0.03 0.08	1.0 0.8 0.1 0.0
Hospital days resulting from AVF / graft complications	2.3 days/yr	1.4 days/yr

Table 2. Catheter Performance Measures
Catheters (per AVF/graft)	1.1
Fractional time using catheter as primary access	0.48
Complications (per catheter)	0.6
- infection - central vein thrombosis	0.55 0.02
Hospital days resulting from AVF / graft complications	2.4 days/yr

Similar rates of suitability for access were observed, with AVF requiring a longer time for initial access but enhanced durability. A majority of the lifespan for both AVF and grafts occurred following the 1^st revision, likely stemming from the frequent need for intervention to assist in maturation. Approximately 1 catheter for each AVF or graft was used to support dialysis. Unfortunately these catheters provide for 48% of the total dialysis needs and require 2.4 inpatient hospital days per year to treat associated complications.
CONCLUSIONS: The majority of AVF will be suitable for cannulation, although interventions are frequently required to both assist in maturation and maintain adequate function. Bridging catheters are frequently needed to assist in the management of these patients, but unfortunately were required to support almost 50% of the total dialysis needs.

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