Superior Patency of Upper Arm Arteriovenous Fistulae in High Risk Patients

Abstract

Despite an increased propensity to primary failure in forearm arteriovenous fistulae compared with upper arm fistulae, forearm fistulae remain the preferred primary access type for chronic hemodialysis patients. In a high risk patient population with multiple medical comorbidities associated with requirement for intravenous access we compared the rates of access failure in forearm and upper arm fistulae. The records of all patients having primary native arteriovenous fistulae placed between 2004 and 2009 at the VA Connecticut Healthcare system were reviewed (n = 118). Primary and secondary patency of upper arm and forearm fistulae were evaluated using Kaplan-Meier survival analysis. The effects of medical comorbidities on access patency were analyzed with Cox regression. The median time to primary failure of the vascular access was 0.288 y in the forearm group compared with 0.940 y in the upper arm group (P = 0.028). Secondary patency was 52% at 4.9 y in upper arm fistulae compared with 52% at 1.1 y in the forearm group (P = 0.036). There was no significant effect of patient comorbidities on fistula failure; however, there was a trend toward upper arm surgical site as a protective factor for primary fistula patency (hazard ratio = 0.573, P = 0.076). In veterans needing hemodialysis, a high risk population with extensive comorbid factors often requiring intravascular access, upper arm fistulae are not only a viable option for primary vascular access, but are likely to be a superior option to classic forearm fistulae.