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16 Vascular Access forHaemodialysis
suggests no improved outcomes regarding patency and overall AVF usability, and
despite the small number of included studies in the comparative analysis, pAVF
displayed a signicant risk decrease regarding steal syndrome and infection occurrence compared with sAVF.Additionally, the minimally invasive nature of the procedure, along with the addition of available anatomic options (eg, deep vein AVF),
enhances the arsenal of physicians treating end-stage renal disease. Nevertheless,
high reintervention and abandonment rates should be kept in mind.
16.2.1.3 Brachiobasilic Arteriovenous Fistulas Vs. Arteriovenous Grafts
It is unclear what the optimal upper extremity hemodialysis access is for patients
without a suitable cephalic vein for AVFs. The objective of a systematic review and
meta-analysis was to compare the outcomes for upper extremity transposed brachiobasilic AVFs (BBAVFs) and AVGs [4]. Twenty-three studies examining 2799
patients were identied and included in the study. The 1-year primary patency rates
(OR=1.68, p = 0.001) and 2-year primary patency rates (OR=2.33, p<0.001)
were signicantly better for BBAVFs than AVGs. Compared to AVGs, the 1-year
secondary patency rates (OR=1.45, p=0.022) and 2-year secondary patency rates
(OR=1.93, p<0.001) were also signicantly higher for BBAVFs. This analysis
supports the preferential placement of BBAVFs over AVGs in patients who have
exhausted radiocephalic and brachiocephalic AVF options.
16.2.1.4 Tapered andNon-tapered Prosthetic Grafts
It is unclear whether tapered AVGs are superior to non-tapered AVGs when it comes
to preventing upper extremity ischemic steal syndrome. Jasty etal. [5] evaluated the
outcomes of tapered and non-tapered AVGs using systematic review and metaanalysis. Five studies involving 4397 patients met the inclusion criteria. There were
no signicant differences for the risk of ischemic steal syndrome (pooled OR 0.92,
p=0.89) between the tapered and non-tapered upper extremity AVG.The primary
patency (OR 1.33, p=0.12%) and secondary patency at 1-year (OR 1.49, p=0.17%),
and rate of infection (OR 0.62, p=0.19) were also similar between the tapered and
non-tapered AVG.This meta-analysis does not support the routine use of tapered
graft over non-tapered graft to prevent ischemic steal syndrome in upper extremity
dialysis access.
16.2.1.5 Regional Anaesthesia Vs. Local Anaesthesia forAV
Fistula Creation
Gao etal. [6] conducted a systematic review and meta-analysis to synthesize evidence from seven randomized controlled trials (565 patients) and one observational
study (408 patients) with the aim of evaluating the safety and efcacy of regional
(RA) versus local anesthesia (LA) for AV-stula creation. Pooled data showed that
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RA was associated with higher primary patency rates than LA (OR, 1.88; P=0.003)
and improved local blood ow compared with LA.Moreover, operation duration
and the use of pain medication was signicantly reduced with RA versus
LA.Brachial plexus block can contribute to vessel dilation and reduced vasospasm
via sympathectomy-like effects, increasing stula blood ow, reducing stula maturation time, and improving the success rates of vascular access procedures.
To study the effects of RA versus LA on longer-term AVF patency, Aitken etal.
[7] performed an observer-blinded randomized controlled trial. 126 patients undergoing primary radiocephalic or brachiocephalic AVF creation were randomly
assigned to receive RA (brachial plexus block) or LA.At 12months, higher primary
patency among patients receiving regional versus local anesthesia (79% versus
59%; OR 2.7; P=0.02) was found as well as higher functional patency (68% versus
49% patients; OR, 2.1; P=0.008). The results also proved RA is cost-effective in
AVF creation. Regional anesthesia resulted in net savings of £195.10 (US$237.36)
per patient at 1year, and an incremental cost-effectiveness ratio of approximately
£12,900 (US$15,694.20) per quality-adjusted life years over a 5-year time horizon.
16.2.1.6 Arteriovenous Fistulae Aneurysms
Aneurysm formation is a complication of vascular access AVF characterised by an
enlargement of all three layers of the vessel wall with a diameter of more than
18mm and has a prevalence of more than 40% in the dialysis population. Baláž
etal. [8] performed a systematic review and meta-analysis evaluating the surgical
options for the treatment of aneurysmal AVF.Thirteen full text articles were included
in the meta-analysis. The total number of patients was 597. Aneurysms were located
in the upper arm in 289 (59%) cases and the smallest diameter of a treated aneurysm
was 15mm. The most frequent indication for treatment was bleeding prevention in
513 (86%) cases. Aneurysmorrhaphy was the surgical method of choice in all 13
studies. The pooled primary patency at 12 months was 82% (12 studies). The
12-month primary patency rates were similar for aneurysmorrhaphy with external
prosthetic reinforcement (85%, two studies) and aneurysmorrhaphy performed
using a stapler (74%, four studies) and without a stapler (82%, six studies). In the
studies included none described covered stent graft implantation. The authors
believed that all symptomatic aneurysmal arteriovenous access stulae should be
treated surgically by aneurysmorrhaphy without external reinforcement (because
prosthetic reinforcement has a potential risk of infection). Aneurysmorrhaphy performed with or without a stapler device seems to be the preferred option.
16.2.1.7 DCB Angioplasty Vs. PBA Angioplasty
forHemodialysis Dysfunction
A meta-analysis presented by Liu et al. [9] compared the safety and efcacy of
drug-coated balloon angioplasty (DCB) and plain balloon angioplasty (PBA) in
treating hemodialysis access dysfunction. A total of 18 randomized controlled trials
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including 877 and 875 patients in the DCB and PBA groups, respectively, were
included. Drug-eluting balloon angioplasty was superior to plain balloon angioplasty during short-term follow-up regarding target lesion patency, circuit patency,
and target lesion revascularization rates with a similar mortality prole. Using drugeluting balloon in treating hemodialysis access dysfunction may reduce the requirement of reintervention and its related healthcare cost compared with plain balloon
angioplasty in the short-term.
Paclitaxel-coated balloon (PCB) angioplasty and PBA for hemodialysis (HD)
access stenosis or occlusion was also investigated by Chen etal. [10]. A total of 16
studies were included in this meta-analysis, 12 randomized controlled trials and 4
cohort studies involving 1086 patients who underwent endovascular treatment for
HD access stenosis or occlusion. This meta-analysis showed a signicant improvement of short-term and midterm primary patency of HD access after treatment with
PCB angioplasty. This favorable outcome was observed in both AVF and central
venous stenosis (CVS). There was no association between paclitaxel and all-cause
mortality in HD patients at 6-, 12-, and 24-month follow-up in this analysis.
However, there was a trend suggesting that PCB angioplasty might increase the risk
of 24- month mortality compared with PBA if the sample size is large enough.
Further studies on long-term mortality are needed to investigate the safety of PCB
angioplasty in patients with ESRD.
Han etal. [11] also compared the efcacy and safety of DCB and PB angioplasty
in treating arteriovenous access stenosis in a systematic review and meta-analysis of
randomized controlled trials. Sixteen eligible trials, including 1682 lesions, were
included in the quantitative analysis for the efcacy and safety of paclitaxel coated
DCBs. DCBs were associated with a lower risk of loss of target lesion patency at
6months (HR 0.53, 95% CI 0.42–0.66) and 12months (HR 0.60, 95% CI 0.47–0.76),
and were also associated with improved six- and 12-month circuit patency. Overall
quality of evidence was moderate to low. Procedural complications were rare, and
the risk of death up to 12months was similar between the two groups. In conclusion, this meta-analysis demonstrated an advantage of DCB angioplasty over PB
angioplasty in treating arteriovenous dialysis access stenosis.
Tripsianis etal. [12] compared the effectiveness of all rst-line endovascular
modalities for the treatment of AVF-related stenosis using a network meta-analysis
(NMA). Eleven randomized controlled trials were included, with 814 patients, 395
of whom had undergone PBA.The network meta-analysis showed that DCBA at
6months was signicantly more effective than PBA (odds ratio, 0.39; 95% condence interval, 0.18–0.81) and ranked as the best treatment option, although the
difference was not statistically signicant compared with cutting balloon angioplasty (odds ratio, 0.65; 95% condence interval, 0.20–2.12). The differences
among the three treatments at 1year were not statistically signicant. Additional
conventional pairwise metaanalyses did not nd signicant differences at 1year.
For patients with failing autogenous AVFs with outow vein stenosis, DCBA was
signicantly superior to PBA, with an improved 6-month failure rate. However, the
effectiveness of DCBA in the long term deserves further investigation.
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16.2.1.8 Distal Revascularization andInterval Ligation (DRIL)
Distal revascularization and interval ligation (DRIL) is one form of treatment of
vascular access-induced ischemia. This intervention preserves the AVF while
relieving or reversing ischemia symptoms. The procedure involves ligation of the
artery immediately distal to the arteriovenous anastomosis site followed by an arterial bypass (artery to artery). This is conducted using a conduit (vein, artery, and
prosthetic material) and anastomosis 5–10cm proximal to the arteriovenous anastomosis from the artery to the distal part of the artery and beyond the ligation site.
Kordzadeh and Parsa [13] examined the efcacy of the procedure through a systematic review. In twenty-two studies 459 individuals were subjected to DRIL.Time to
ischemia was 196days. Ischemia grade 3/4 (52%) was the most common presentation. The overall success (grades 1–4) was 81% during a mean and median follow up of 22.2months and 18months, respectively. The conduit of choice was the great
saphenous vein (n= 300/459 [65%]), and bypass thrombosis was highest in the
polytetrauoroethylene group (n= 19/44 [43%]). DRIL is an effective modality
(grade of recommendation B, level of evidence III/IIb) in the treatment of vascular
access-induced ischemia in upper limb AVF and could be successful in 81%
of cases.
16.2.1.9 AV Fistula Closure inRenal Transplant Recipients
Ligating an AVF after successful renal transplantation remains a matter of debate.
Zheng et al. [14] performed a meta-analysis to evaluate the cardiac effects and
allograft function after AVF closure, as well as to assist in deciding whether to preserve or ligate the AVF. 10 studies were included in this meta-analysis. Kidney
transplant recipients with occluded AVF had lower left ventricular mass index and
left ventricular end-diastolic diameter values compared with patients with patent
AVF.Patients with occluded AVF also had lower serum creatinine levels versus
those with patent AVF.No difference was seen regarding ejection fraction between
the groups. The meta-analysis showed that AVF closure improves cardiac morphology and is associated with better kidney graft function. Therefore, AVF closure may
be considered in patients with well-functioning allografts.
Rao et al. [15] presented the rst randomized controlled trial looking at the
effects of arteriovenous stula ligation on cardiac magnetic resonance imaging–
derived left ventricular mass in kidney transplant recipients. Fifty-four participants
completed the study: 27in the AVF ligation group and 27in the control group. The
primary end point showed a mean decrease of 22.1g in LVM in the AVF ligation
group compared with no signicant change in the control group (P < 0.001).
Signicant decreases in LV end-diastolic volumes, LV end-systolic volumes, cardiac output, cardiac index, atrial volumes, and NT-proBNP were also seen in the
AVF closure group (P<0.01). No signicant changes were observed in LV ejection
fraction (P= 0.93) and pulmonary artery velocity (P = 0.07). These results have
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signicant implications for the management of cardiovascular risk after kidney
transplantation, given that a single intervention, undertaken as a day procedure, has
the potential to provide substantial cardiovascular benets.
16 Vascular Access forHaemodialysis
16.2.2 Clinical Trials andRegistries
16.2.2.1 Hemodialysis Access Type andMortality
Hicks etal. [16] analyzed the effects of age and initial dialysis access type on allcause mortality. The study included 507,791 patients (63.4 ± 0.02 years; 56.5%
male; 40.9% mortality; follow-up, 1.57±1.36years). Increasing age was a signicant predictor of overall mortality (adjusted hazard ratio [aHR], 1.03; P<.001).
Compared with patients with hemodialysis catheters (HCs, n=418,932), overall
risk-adjusted mortality was lowest in patients with AVFs (n=71,316; aHR, 0.63;
P<.001) followed by AVGs (n=17,543; aHR, 0.83; P<.001). AVF was superior
to both HC and AVG for all age groups (P<.001). However, there was a signicant
change in the relative efcacy of AVG at ages 48years and 89years based on spline
modeling; there were no signicant differences comparing adjusted mortality with
AVG vs HC for patients aged 18 to 48years or for patients >89years, but AVG was
superior to HC for patients 49 to 89years of age (aHR, 0.811; P<.001). The mortality benet of AVF was consistently superior to that of AVG and HC for patients of
all ages (all, P<.001). AVF is superior to AVG and HC regardless of the patient’s
age, including in octogenarians. In contrast, the mortality benet of AVG over HC
may not apply to younger (18–48years) or older (>89years) age groups. All patients
18 to 48years should receive AVF for dialysis access whenever possible.
Malas etal. [17] performed a retrospective analysis of the cohort of patients in
the United States Renal Data System (USRDS) database who initiated dialysis
between January 1, 2006, and December 31, 2010. Patients who initiated dialysis
using AVF vs arteriovenous graft (AVG) vs HC were compared. 71,452 (14.0%)
patients initiated HD with AVF, 17562 (3.4%) initiated with AVG, and 420,986
(82.5%) initiated with HC.Survival at 1year was 78% in the HC group compared
with 84% for the AVG group and 89% for the AVF group (Wilcoxon P<.001). Fiveyear survival in the HC group was 45% compared with 48% in the AVG group and
55% in the AVF group (Wilcoxon P< .001). A Cox proportional hazard model
showed a 35% reduction in mortality rate in the AVF group compared with the HC
group (P<.001) and an 18% reduction in mortality rate in the AVG group compared
with the HC group (P< .001). Initiating HD with an AVF provides a signicant
mortality benet compared with initiating dialysis with an AVG or HC.Despite this,
most patients in the United States initiate HD with HC, and incident AVF use falls
markedly short of the initial Kidney Disease Outcomes Quality Initiative target of
50% that was established more than 15years ago.
The aim of a study presented by Locham etal. [18] was to use a large national
renal database to report the incidence and risk factors of sepsis in patients with
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end- stage renal disease (ESRD) initiating HD access using AVF, AVG, or HC in the
United States. All patients with ESRD initiating HD access (AVF, AVG, HC)
between January 1, 2006, and December 31, 2014, in United States Renal Data
System were included. A total of 870,571 patients were identied, of whom, 29.8%
(n= 259,686) developed sepsis. HC (31.2%) and AVG (30.6%) were associated
with a higher number of septic cases compared with AVF (22.9%; P<.001). The
incident rate of sepsis was 12.66 episodes per 100 person-years. It was the highest
among HC vs AVG vs AVF (13.86 vs 11.49 vs 8.03 per 100 person-years).
Compared with patients with no sepsis, sepsis was associated with a three-fold
increase the odds of mortality (odds ratio, 3.16; 95% CI, 3.11–3.21; P < .001).
Additionally, in patients who developed sepsis, AVF use was associated with signicantly lower mortality compared with AVG and HC (73.7% vs 78.7% vs 78.0%;
P<.001). After adjusting for signicant covariates, compared with AVF, mortality
at 1 year after sepsis was 21% higher in AVG (HR, 1.21; 95% CI, 1.15–1.28;
P< .001) and nearly doubled in HC (HR, 1.94; 95% CI, 1.88–2.00; P< .001).
Sepsis risk in HD patients is clearly related to access type and is associated with
dramatic increase in mortality. Initiating HD access with AVF to meet the National
Kidney Foundation Kidney Disease Outcomes Quality recommendations should
be implemented to reduce the incidence of sepsis and improve survival in patients
with ESRD.
16.2.2.2 Permanent Vascular Access Type forElderly Patients
There is inadequate evidence regarding the rst permanent vascular access type and
risk of mortality or hospitalization among the elderly population undergoing hemodialysis. Lyu etal. [19] emulated a randomized controlled trial using observational
data to compare the effect of AVF versus AVG creation on the risks of mortality,
hospitalization, and sepsis among elderly patients receiving HD.Elderly patients
registered in the US Renal Data System were enclosed. Inclusion criteria were initiation of HD between 2013 and 2014, age≥67years at HD initiation, no AVF/
AVG created before HD initiation, and a rst AVF/AVG created within 6months
after HD initiation. A total of 19,867 patients were included for the analyses, with
80.1% receiving an AVF and 19.9% an AVG.In unweighted analysis, AVF creation
was associated with signicantly lower risks of mortality and hospitalization, especially within 6months after vascular access creation. In inverse probability of treatment weighting analysis, AVF creation was associated with lower incidences of
mortality and hospitalization within 6months after creation for mortality and allcause hospitalization, respectively), but not between 6months and 3 years after
access creation. No association between AVF creation and mortality, sepsis, or allcause, cardiovascular disease-related, or infection-related hospitalization was found
in instrumental variable analyses. However, AVF creation was associated with a
lower risk of access-related hospitalization not due to infection. Using observational
data to emulate a target randomized controlled trial, the type of initial arteriovenous
access created was not associated with the risks of mortality, sepsis, or all-cause,
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cardiovascular disease-related, or infection-related hospitalization among elderly
patients who initiated HD with a catheter and had an AVF/AVG created within
6months.
16.2.2.3 Hemodialysis Access inDiabetic Patients
A retrospective study evaluated the effect of diabetes on outcomes of autogenous
stulas and prosthetic grafts for hemodialysis access in a large population-based
cohort of patients [20]. The United States Renal Database System (2007–2014) was
used. The study of 381,622 patients comprised 303,307 (79.5%) autogenous stulas
and 78,315 (20.5%) prosthetic grafts placed in 231,134 (60.6%) diabetic patients
and 150,488 (39.4%) nondiabetic patients. There was decrease in maturation for
diabetics compared to nondiabetics who received autogenous stulas and prosthetic
grafts. Comparing diabetics vs nondiabetics, primary patency at 5years was 19.4%
vs 23.5% (P<.001) for autogenous stulas and 9.1% vs 11.2% (P<.001) for prosthetic grafts. In this population-based cohort of hemodialysis patients, diabetes mellitus was associated with a decrease in patient survival, access maturation, and
primary stula patency. In contrast, there was no association between diabetes and
prosthetic graft patency and severe prosthetic graft infection warranting excision.
Further details are given in Table16.1.
16.2.2.4 Brachiobasilic AV Fistula—One-Stage Vs. Two-Stage
The brachiobasilic arteriovenous stula (BBAVF) can be created successfully using
either a one-stage or a two-stage procedure [21]. For the one-stage procedure, the
transposition of the basilic vein and arteriovenous anastomosis are performed during the same procedure. In the two-stage approach, a rst procedure is typically
used to create the arteriovenous anastomosis through an incision at the antecubital
fossa. This is followed by a second procedure later to elevate or to transpose the
arterialized vein. A new arteriovenous anastomosis may or may not be required. The
Table 16.1 Kaplan-Meier estimates of primary patency, secondary patency and survival for
diabetic and non-diabetic patients who received autogenous AV stulas or prosthetic grafts
(according to [20])
Outcome AV stula/diabetic AV stula/non-diabetic Graft/diabetic Graft/non-diabetic
Primary patency (%)
–1year 40.5 46.0 30.3 31.6
–3years 26.8 31.8 13.6 16.0
Secondary patency (%)
–1year 60.8 64.2 58.3 59.4
–3years 51.9 55.8 43.7 45.5
Patient survival, %
–1year 83.2 83.7 76.9 75.8
–3years 58.5 62.2 49.7 51.1
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theoretical advantages of the one-stage procedure include the shorter time between
the stula creation and cannulation for dialysis and the requirement for only one
procedure. The downside of this approach is the use of an extended incision if the
stula fails to mature and the risk of injuring the unarterialized basilic vein during
surgery. In comparison, the two-stage procedure leaves the patient with a smaller
antecubital incision if the stula fails. In addition, the mobilization of the larger
arterialized vein may be technically easier in the two-stage approach. Tan etal. [21]
identied 2648 patients who had received BBAVFs within the Vascular Quality
Initiative data set (2010–2016) and compared those created using the one-stage and
two-stage technique. There were 1234 (47%) one-stage and 1414 (53%) two-stage
BBAVFs in the study cohort. Patients undergoing one-stage BBAVFs had larger
vein diameters (4.1 vs 3.4mm; P < .001) and the procedure was more often performed in an inpatient setting (21% vs. 13%; p<0.001) compared with patients
undergoing a two-stage procedure. The 12-month primary patency rate was higher
for the one-stage BBAVF (49.1% vs 40.4%; P = .005), although the secondary
patency rate was comparable (80.0% vs 77.9%; P=.54). In multivariable analysis,
although loss of primary patency at 12months and 3-month wound infection were
similar between the two approaches, the risk of 3-month arm swelling was signicantly lower for two-stage BBAVFs (aHR, 0.35; 95% CI, 0.16–0.77; P=.009). Both
types of BBAVF approaches should be considered standard of care. Most surgeons
in the VQI favored a two-stage procedure for patients with a smaller basilic vein and
those with a history of failed access.
16.2.2.5 End-to-Side or Side-to-Side Arteriovenous Anastomosis forAVF
ElKassaby etal. [22] compared the results of both surgical techniques, end-to-side
(ETS) or side-to-side (STS) anastomosis between artery and vein for creation an
AVF in a randomized prospective controlled setting with 50 patients each. Primary
and secondary patency rates at 12months were 76% ETS vs. 78% STS (P=0.381)
and 84% ETS vs. 86% STS (P= 0.225), respectively. The ability of the access to
withstand 6 consecutive full dialysis sessions within a period of 30days was dened
as functional maturation of AVF.This parameter showed the most signicant difference between the two groups of the study population, with clear favour for the ETS
technique (70% vs. 34%, P=0.0001). This was also reected in the results of maximum ow achieved during the rst three dialysis sessions. Considering these results,
the authors recommended the ETS technique when creating AVF.
16.2.2.6 Surgical Vs Percutaneous AV Fistulas
In a single-center retrospective study, Harika et al. [23] compared the rst 107
patients who had undergone percutaneous arteriovenous stula (p-AVF) creation
with the Ellipsys system from May 2017 to May 2018 with an equal number of
consecutive patients who had undergone surgical arteriovenous stulas (s-AVFs).
The p-AVFs showed superior maturation rates at 6weeks (65% vs 50%; P=.01).
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The primary patency rates were greater for the s-AVFs at 12months (86% vs 61%;
P < .01). However, primary patency was comparable between the two groups at
24months (52% vs 55%; P=.48). No signicant difference was found in the secondary patency rates at 12 (90% vs 91%) and 24 (88% vs 91%) months. At the
2-year follow-up point, the rate of percutaneous reintervention was similar; however, the s-AVFs had required more frequent surgical revision (36% vs 17%;
P= .01). Issues with wound healing and infection were also more frequent with
s-AVFs (9% vs 0.9%; P<.01). These data support the conclusion that p-AVFs have
results comparable, and in some respects superior, to those of s-AVFs.
Shahverdyan etal. [24] compared the Ellipsys percutaneous AVF (n=89) with a
proximal forearm Gracz-type surgical AVF (n=69) in a retrospective study of prospectively collected clinical data. The Gracz-type AVF is a proximal forearm arteriovenous stula involving an end-to-side anastomosis between a perforating branch
of the cephalic or median antecubital vein and the brachial or proximal radial artery.
Technical success was 100% for both groups. Average procedure times were 14min
for percutaneous AVFs and 74min for surgical AVFs (P<0.001). Proximal radial
artery (PRA) was used in all percutaneous AVF cases. Inow for surgical AVFs
included radial (30%), ulnar (12%), and brachial (58%) arteries. Outow veins for
both groups were the cephalic and/or basilic veins. Access ow volumes, times to
maturation, and overall numbers of interventions per patient-year were not signicantly different. Cumulative incidence of primary patency failure at 12months was
lower for surgical AVF (47% vs 64%, P=0.1), but secondary patency failure was
not different between groups (20% vs 12%, P=0.3). PRA surgical AVFs had similar primary patency (65% vs 64%, P=0.8) but higher secondary patency failure
rates than percutaneous AVFs at 12months (34% vs 12%, P=0.04). When a distal
radial artery AVF is not feasible, percutaneous AVF might offer an appropriate procedure for creating a safe and functional access, maintaining further proximal forearm surgical AVF creation options.
Mordhorst etal. [25] compared autogenous arteriovenous access created with the
EverlinQ endoAVF system with accesses created by conventional surgical technique with respect to functional and patency related outcomes. A total of 369
accesses were created during the study period, including 61 endovascular accesses,
171 radiocephalic accesses, and 137 brachiocephalic accesses (median follow-up,
17months; range, 1–71 months). Maturation failure at the end of follow-up was
27%±6%, 27%±5%, and 18%±4% for endovascular, radiocephalic, and brachiocephalic accesses, respectively (P = .049 for brachiocephalic vs endovascular
accesses). Primary patencies at 12 and 24months were 42%±5% and 32%±7%
for endovascular accesses, 43%± 4% and 24% ± 4% for radiocephalic accesses,
and 42%±4% and 29%±4% for brachiocephalic accesses (P=.906). Secondary
patencies at 12 and 24months were 68%±6% and 60% ± 7% for endovascular
accesses, 75%±3% and 67%±4% for radiocephalic accesses, and 91%±3% and
81%±4% for brachiocephalic accesses (P=.006 for brachiocephalic vs endovascular accesses). There were no statistically signicant differences in ischemic steal.
Endovascular arteriovenous accesses were comparable to radiocephalic stulas
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with respect to maturation and patency; however, they were inferior to brachiocephalic accesses. EndoAVF should not be seen as a replacement for surgically created dialysis access. Rather, it is another option which can be used in attempts to
preserve more proximal creation.
16.2.2.7 Early Cannulation Arteriovenous Grafts
Tawk etal. [26] recruited 477 hemodialysis patients indicated for vascular access
creation and compared outcomes with standard AV grafts (PTFE) (n= 236) with
those using early cannulation grafts (ACUSEAL, n=241) in a single center randomized controlled trial. Primary patency rate was 65.7% and 68.0% (P=.58) at
6months and 53.8% and 56.4% (P=.57) at 12months in the standard AVG (sAVG)
and early cannulation AVG (eAVG) groups, respectively. Primary assisted patency
rate was 70.8% and 69.7% (P=.8) in patients with sAVG and eAVG at 6months,
whereas the reported rates at 12months were 59.3% and 61.0% (P=.71) respectively. Patients in the eAVG group experienced signicantly earlier cannulation
when compared with patients in the sAVG group (median, 3.0 days; range,
1.0–9.0 days vs 19.0 days; range, 15.0–22.0 days; P < .001). Early cannulation
grafts had comparable 12-month outcomes to standard grafts with the added advantage of earlier time to rst cannulation.
In a retrospective cohort study, too, eighteen-month patency and infection rates
were similar between 148 standard (sAVG) and 62 immediate-access arteriovenous
grafts (IAAVG), but immediate-access grafts had fewer secondary procedures and
allowed earlier cannulation and tunneled catheter removal, thereby signicantly
decreasing catheter-related complications [27]. Primary patency was similar at both
1 year (sAVG, 39.4%; IAAVG, 56.7%; P = .4) and 18 months (sAVG, 29.0%;
IAAVG, 43.7%; P=.4). Overall survival was 48% at 24months. IAAVG patients
required fewer overall additional procedures to maintain patency (mean number of
procedures, 0.99 for sAVGs vs 0.61 for IAAVGs; P=.025). There was no difference
in occurrence of steal syndrome (sAVG, 6.8%; IAAVG, 8.1%; P = .74) or graft
infection (sAVG, 19.0%; IAAVG, 12.0%; P = .276). Seventy-ve percent of all
grafts were successfully cannulated, with shorter median time to rst cannulation in
the IAAVG group (6days; interquartile range [IQR], 1–19days) compared with the
sAVG group (31days; IQR, 26–47days; P<.01). Catheter-related complications
occurred less frequently in the IAAVG group (16.4% vs 2.9%; P<.045).
Mohapatra et al. [28] constructed a Markov state-transition model in which
patients initially received either an IAAVG or an sAVG and a tunneled dialysis catheter (TDC) until graft usability; patients were followed through multiple subsequent
access procedures for a 60-month time horizon. IAAVG placement was a dominant
strategy under both real-world ($1201.16 less expensive and 0.03 QALY more
effective) and ideal ($1457.97 less expensive and 0.03 QALY more effective) conditions. The mean catheter time was lower with IAAVG (3.9 vs 8.7months; P<.0001),
as was the mean number of access-related infections (0.55 vs 0.74; P < .0001).
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