Two-Year Outcomes of Early Cannulation Arteriovenous Grafts for End-Stage Renal Disease

Abstract

Almost 80% of patients with end-stage renal disease (ESRD) initiate dialysis via a central venous catheter (CVC). CVCs are associated with multiple complications and a high cost of care. The purpose of our project is to determine the impact of early cannulation arteriovenous grafts (ECAVGs) on quality of care and costs. The dialysis access modality, complications, secondary interventions, hospital outcomes, and detailed costs were tracked for 397 sequential patients who underwent access creation between July 2014 and October 2018. Complications were grouped into deep vein thrombosis, line infections, sepsis, pneumothorax, and other. Secondary interventions included angioplasty, angioplasty and stent grafting, thrombectomy, surgical revision, and explantation. Hospital outcomes included length of stay, inpatient mortality, 30-day readmission, and discharge disposition. Costs included supplies, medications, laboratory tests, labor, and other direct costs. All variables were measured at the time of the index procedure, 30days, 90days, 180days, 270days, 1 year, 18months, and 2 years. There were 131 patients who underwent arteriovenous fistula (AVF) and 266 who received ECAVG for dialysis access. The total cost of care per patient was $17,523 for AVF and $5,894 for ECAVG at 1 year (P<0.01). Primary-assisted patency for AVF was 49.3% versus 81.4% for ECAVG (P=0.027), and secondary-assisted patency for AVF was 63.8% versus 85.4% for ECAVG at 1 year (P=0.011). There was a survival advantage for ECAVGs at 1 year (78.6% for AVF vs 85.0% for ECAVG, P=0.034). Patients who received ECAVG had fewer CVC days (2.3% vs 19.1% for AVF, P<0.001), fewer complications (1.6% vs. 21.5% for AVF, P<0.001), and fewer secondary interventions (17.0% vs 52.5% for AVF, P<0.001). This is the first study on patients with ESRD to report detailed outcomes and cost analysis as it relates to AVF versus ECAVG. ECAVGs have an advantage over AVFs due to lower overall cost and better clinical outcomes at 1 year. Implementation of an urgent start dialysis access program centered around ECAVGs may help achieve the national goal of better health care at a lower cost for patients with ESRD.