Alik Farber1, Bo Hu2, Laura Dember3, Gerald Beck2, Brad Dixon5, John Kusek4, Harold Feldman3
1Boston University Medical Center, Boston, MA; 2Cleveland Clinic, Cleveland, OH; 3University of Pennsylvania, Philadelphia, PA; 4National Institutes of Health, Bethesda, MD; 5University of Iowa, Iowa City, IA.
OBJECTIVES: Arteriovenous grafts (AVG) are used in hemodialysis patients when autogenous fistulas are not feasible. The optimal location (forearm vs. upper arm) and configuration (loop vs. straight) of AVG is not known. To evaluate relationships between AVG location or configuration and patency, we conducted subgroup analyses among participants enrolled in a randomized, placebo-controlled trial of dipyridamole plus aspirin for newly placed AVG.
METHODS: Participants in the Dialysis Access Consortium trial with upper extremity prosthetic grafts of the brachial artery were studied. Multivariable analyses adjusting for treatment group, center, gender, race, BMI, diabetes, current dialysis, and prior access or catheter were performed to compare outcomes of forearm (fAVG) and upper arm (uAVG) grafts including loss of primary unassisted patency (LPUP) and cumulative primary graft failure (CGF). Subgroup analyses of graft configuration and outflow vein used were conducted.
RESULTS: Of the 522 participants with an upper extremity brachial artery graft, 269 had fAVG and 253 had uAVG. Participants with fAVG were less often male (33% vs. 43%, p=0.03), black (62% vs. 77%, p<0.001), dialysis-dependent at time of surgery (20% vs. 36%, p<0.001), and had a higher mean BMI (32 vs. 29, p<0.001) compared to those with uAVG. There was no difference in LPUP(69% vs 78%,p=0.22) or CGF(32% vs 36%, p=0.53) between fAVG and uAVG at 1 year follow-up. Multivariable adjustment did not change the statistical significance of the association between AVG location and either LPUP (HR1.26,95%CI [0.98,1.62], p=0.07) or CGF (HR=1.09, 95% CI [0.80,1.49], p=0.58). LPUP did not differ significantly between fAVG and uAVG among subgroups based on AVG configuration (p=0.23) or outflow vein used (p=0.53).
CONCLUSIONS: Patency of fAVG and uAVG was similar despite the larger caliber veins often encountered in the upper arm. Therefore, to preserve a maximal number of access sites, the forearm location should be considered first before resorting to an upper arm graft.
AUTHOR DISCLOSURES: G. Beck: Nothing to disclose; L. Dember: Nothing to disclose; B. Dixon: Nothing to disclose; A. Farber: Nothing to disclose; H. Feldman: Nothing to disclose; B. Hu: Nothing to disclose; J. Kusek: Nothing to disclose.
Posted April 2013