Outcomes of AVF Fistula Creation
Ajay K. Singh, MBBS, FRCP
Brigham and Women's Hospital
Harvard Medical School
Editor's Note: This is an article in CJASN by Schinstock et al from Karl Nath's group at the Mayo (Clin J Am Soc Nephrol 6: 1996-2002, 2011).CJASN link
Ajay K. Singh, MBBS, FRCP
Brigham and Women's Hospital
Harvard Medical School
Editor's Note: This is an article in CJASN by Schinstock et al from Karl Nath's group at the Mayo (Clin J Am Soc Nephrol 6: 1996-2002, 2011).CJASN link
- Context
- Vascular access is a major source of morbidity in hemodialysis patients
- Poses substantial financial burden
- Fistula First Initiative has been successful in increasing AVF placement rates
- Bottom-line
- Artery size is the only predictor of primary and secondary AVF patency.
- The investigators also report that primary failure remains a major issue in the post-Fistula first era.
- Significance of Study
- The importance of pre-operative pre-operative ultrasound and Doppler mapping of vessels in each arm and ultrasound examination of central veins.
- There is a complication rate that should be taken into account as one educates the patient about AVF placement.
- Limitations
- Single Center (Mayo)
- Mostly caucasians (88.1%)
- Possibility of referral bias
- Details
- This was a retrospective study from a single center (the Mayo Clinic) conducted from 2006 to 2008. All of the patient's underwent pre-operative ultrasound and Doppler mapping of vessels in each arm and ultrasound examination of central veins.
- 317 AVFs were placed in 293 patients. The primary outcome was secondary patency, which was defined as "the time from AVF creation to access abandonment". Other outcomes included suitability for hemodialysis, primary failure, secondary failure, and primary patency. [The definitions for these secondary outcomes are provided in the paper].
- The primary failure rate was 37.1%.
- Of usable AVFs, 11.4% later failed.
- AVF creation incurred complications and hospitalization in 21.2% and 12.3% of patients, respectively.
- Complications included bleeding (33%), infection (26.8%), steal syndrome (18.3%), aneurysm (8.5%), thrombosis (4.9%), seroma (4.9%), subclavian stenosis (2.4%), and nerve injury (1.2%).
- Hospitalizations - "were usually because of an unexpected complication or AVF thrombosis"
- The risk for reduced primary patency was increased by diabetes
- The risk for primary and secondary patency was decreased with larger arteries.
