The Natural History of Vascular Access For Hemodialysis: A Single Center Study of 2,422 Patients

Abstract

Conclusion: With the possible exception of older patients with diabetes, autogenous conduits are preferable for dialysis access. Summary: The Clinical Guidelines for Vascular Access from the National Kidney Foundation Disease Outcomes Quality Initiative recommend radial-cephalic arteriovenous fistulas (AVFs) and brachial-cephalic AVFs as the first and second choices for dialysis access, followed by prosthetic grafts, brachial-basilic AVFs, and venous catheters as secondary choices. These recommendations have been verified by review articles and small prospective trials and small clinical series. The article represents a retrospective review of a very large dialysis access experience in which 2422 consecutive patients underwent 3685 vascular access procedures in a tertiary care hospital. Radial-cephalic, brachial-cephalic, brachial-basilic, and prosthetic graft fistulas were all performed. Maximum follow-up was 20 years, and patency rates were determined by Kaplan-Meier analysis. Median primary patency for radial-cephalic AVFs was 712 days (95% confidence interval [CI], 606-818 days). Median primary patency for brachial-cephalic AVFs was 1009 days (95% CI, 823-1195 days). Median primary patency for PTFE reconstructions was 384 days (95% CI, 273-945 days). Median secondary patency for radial-cephalic fistulas was 1809 days (95% CI, 1692-1582 days). Median primary patency of brachial-basilic AVFs (second or third choice for vascular access) was 1582 days (95% CI, 415-2749 days). The cumulative incidence of clinically important complications in patients receiving radial-cephalic, brachial-cephalic, brachial-basilic, and PTFE dialysis access was 0.25, 0.57, 0.33, and 0.61 per patient-year, respectively. After 2000 days, radial-cephalic AVF patency was superior to brachial-cephalic AVF patency. Ten years after construction, 18% of radial-cephalic AVFs and 12% of brachial-cephalic AVFs were still functional. More than 50% of brachial-basilic arteriovenous fistulas were still patent after 4 years. Comment: The value of this study lies in the large number of patients and the long period of follow-up. Otherwise, the conclusions are really not substantially different from those derived previously. There has, however, been some controversy about the use of prosthetic vs brachial-basilic fistulas as secondary or tertiary access procedures. This study would suggest that a brachial-basilic fistula is far superior to prosthetic access and that brachial-basilic AVF, although more technically demanding, should be the preferred secondary or tertiary access over a prosthetic graft.