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PVSS24. The Natural History Of First Time Hemodialysis Access: Arteriovenous Fistulas Versus Prosthetic Bridge Grafts

Andre Biuckians, Eric C. Scott, George H. Meier, Jean M. Panneton, Marc H. Glickman.
Eastern Virginia Medical School and Vascular & Transplant Specialists, Norfolk, Va.

OBJECTIVES: Patients on hemodialysis depend on durable, easily maintained vascular access and the autologous arteriovenous fistula (AVF) has been the gold standard since its introduction in 1966. The purpose of this study was to compare the natural history of AVF and prosthetic grafts (AVG) in patients who present for first-time access surgery.

METHODS: We performed a retrospective review of patients undergoing new access creation from January, 2005 through June, 2005. All patients who had prior permanent access procedures were excluded and the study group consisted of first-time access patients only. Categorical data was compared using chi-square analysis, nominal data was compared using Student’s t-test, and patency was determined with Kaplan-Meier survival curves.

RESULTS: One-hundred and nineteen first-time access procedures were performed, of which 80 were AVF (67%) and 39 were AVG (33%). Demographics and co-morbidities were similar between groups. AVF were primarily created in male patients (69%) and AVG were more commonly placed in female patients (70%). A majority of patients underwent preoperative vein mapping (76% and 82% for AVF and AVG, respectively). The mean vein diameter used in AVF creation was 3.1 mm versus 2.3 mm in the AVG group (p<.001). Mean follow-up was 278 days and 272 days for AVF and AVG, respectively. There were 16 (20%) primary failures in the AVF group and no primary failures in the AVG group. AVF received 2.1 interventions/patient-year compared to 2.6 intervention/patient-year in AVG. The mean time to successful cannulation was 146 days for AVF compared to 99 days (median=77) for AVG. There were 3 (7.6%) AVG infections and none in AVF. One-year primary, primary-assisted, and secondary patency was 36%, 55%, 55% and 18%, 45%, 68% for AVF and AVG, respectively (p=.6). The cumulative 1-year functional patency was 38% and 54% for AVF and AVG, respectively (p=.12).

CONCLUSIONS: The majority (67%) of first-time access procedures were autologous fistulas per K/DOQI guidelines. AVF demonstrated high rates of primary failure, lengthy maturation times, and similar 1-year patency compared to AVG. Both groups required a similar number of interventions per patient to achieve or maintain function. These results are the first to compare the natural history of arteriovenous fistulas versus prosthetic grafts in contemporary, simultaneous patient populations.