Autologous arteriovenous fistulas in octa- and nonagenarians

Abstract

Conventional wisdom has argued for refraining from performing autologous fistulas on elderly population with the rationale that they may not live long enough to benefit from them. However, with aging patient population and increasing prevalence of end-stage renal disease, one has to question if physicians should really be holding advanced age against offering dialysis access to patients who otherwise may be considered an acceptable risk for tolerating an elective operation. It is compounded by the fact that majority of the fistulas can be performed under local anesthesia or nerve block. In the retrospective analysis of over 300,000 patients in the USRDS database, Arhuidese at al1Arhuidese I.J. King R.W. Elemuo C. Agbonkhese G. Calero A. Malas M. Age based outcomes of autogenous fistulas for hemodialysis access.J Vasc Surg. 2021; 74: 1636-1642Abstract Full Text Full Text PDF Scopus (1) Google Scholar found a trend in progressive decrease in primary, primary assisted, and secondary patency in octa- and nonagenarians. This difference may very well be attributable to increased incidence of coexisting comorbidities in elderly; however, a cause-and-effect relationship cannot be established based on the retrospective nature of this analysis. The key take-away point from this analysis is that patients over 80 years of age had primary patency rates of over 35% at 1 year and up to 18% at 5 years. For elderly patient population on hemodialysis, dialysis catheter infections can be catastrophic, and if an autogenous fistula can be successfully created to mitigate the risk of catheter-related infections, it can be of significant benefit to this cohort of patient population. It is the need of the hour that vascular surgeons should individualize the decisions about dialysis access creation to individual patients, regardless of their ages. Decision to proceed with an elective operation to create dialysis access should be made after a careful consideration of risks and benefits of the proposed procedure, including a thorough review of the existing comorbidities. Age in itself should not be used to determine the risk-benefit ratio for elective procedures. Published literature on other vascular surgery procedures has shown that modified frailty index, which takes many coexisting factors, in addition to age, into account, is a better tool to assess the perioperative morbidity and mortality. With increasing proportion of elderly population, we will have to make these decisions more frequently in the near future and getting familiar with tools like modified frailty index will be of immense value for practicing vascular surgeons. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Age-based outcomes of autogenous fistulas for hemodialysis accessJournal of Vascular SurgeryVol. 74Issue 5PreviewHemodialysis (HD) dependence and autogenous fistula use for HD span the spectrum of age. This study examines age-related outcomes of autogenous fistulas for HD access in a large population-based cohort of patients. Full-Text PDF