RS07. Comparative Effectiveness of One-Stage vs Two-Stage Basilic Vein Transposition Arteriovenous Fistula

Abstract

Basilic vein transposition (BVT) fistula may be performed as either one- or two-stage operations, although there is debate within the vascular surgery community as to which technique is superior. This study was designed to evaluate the comparative effectiveness of one-stage vs two-stage BVT. We identified all patients at a single large academic hospital who had undergone creation of either a one-stage or two-stage BVT between January 2007 and December 2014. Data evaluated included patient demographics, comorbidities, medication usage, reasons for abandonment, and all secondary interventions performed to maintain patency. Outcomes were failure or abandonment of the fistula and survival during follow-up. Statistical comparisons between one-stage and two-stage BVT procedures were performed using multivariate Cox proportional hazards models and Kaplan-Meier analysis with log-rank tests. We identified 128 patients, in whom 57 (44%) one-stage BVT and 74 (56%) two-stage BVT fistulas were created among 8 different vascular surgeons during the study time period. There was no significant difference in the mean age (54 vs 53 years; P = .9), male gender (46% vs 53%; P = .4), Caucasian race (63% vs 62%; P = .9), diabetes (72% vs 74%; P = .8), or coronary artery disease (54% vs 57%; P = .8) among patients undergoing one-stage vs two-stage BVT. Similarly, medication adherence for antiplatelet therapy (44% vs 49%; P = .6) and statin therapy (46% vs 50%; P = .6) was comparable between patients undergoing one and two-stage BVT. Following fistula transposition, the median follow-up time was 8.3 months (interquartile range, 3-21 months). Patency rates of one-stage BVT were 56% at 12 months and 43% at 24 months of follow-up, whereas patency rates of two-stage BVT were 79% at 12 months and 70% at 24 months of follow-up. However, there was no difference between groups in use of secondary interventions (58% one-stage vs 51% two-stage; P = .5) to maintain patency. Using Kaplan-Meier estimates (Fig), two-stage BVT had a significant higher patency after 24 months of follow-up (P < .001 by log-rank test). These findings were confirmed in multivariate analysis, where two-stage BVT were associated with significant lower rate of failure (hazard ratio, 0.39; 95% confidence interval, 0.2-0.8; P < .05) than one-stage BVT after controlling for patient and procedure-level factors. Finally, there was no significant difference in 1-year survival between one and two-stage BVT. Our data show that two-stage BVT are more durable than one-stage procedures, with significant lower rates of failure among comparable risk-stratified patients. These findings suggest that additional resources associated with creating two-stage BVT are justified by their long-term benefits.