From the Society for Vascular Surgery

Immediate-access grafts provide comparable patency

to standard grafts, with fewer reinterventions and
catheter-related complications
Jason K. Wagner, MD, MSc,a Ellen Dillavou, MD,b Uttara Nag, MD,b Adham Abou Ali, MD,a
Sandra Truong, MPH,a Rabih Chaer, MD, MSc,a Eric Hager, MD,a Theodore Yuo, MD, MSc,a
Michel Makaroun, MD,a and Efthymios D. Avgerinos, MD,a Pittsburgh, Pa; and Durham, NC

ABSTRACT
Background: No independent comparisons, with midterm follow-up, of standard arteriovenous grafts (SAVGs) and
immediate-access arteriovenous grafts (IAAVGs) exist. The goal of this study was to compare “real-world” performance of
SAVGs and IAAVGs.
Methods: Consecutive patients who underwent placement of a hemodialysis graft between November 2014 and April
2016 were retrospectively identified from the electronic medical record and Vascular Quality Initiative database at two
tertiary centers. Only primary graft placements were included for analysis. Patients were divided into two groups based
on the type of graft implanted. Patients’ comorbidities, graft configuration, operative characteristics, and follow-up were
collected and analyzed with respect to primary and secondary patency. Additional outcomes included graft-related
complications, time to first cannulation, time to tunneled catheter removal, catheter-related complications, and over-
all survival. Patency was determined from the time of the index procedure; c2, Kaplan-Meier, and Cox regression analyses
were used, with the P value set as significant at < .05.
Results: There were 210 grafts identified, 148 SAVGs and 62 IAAVGs. At baseline, the patients’ characteristics were similar
between groups, except for a greater prevalence of preoperative central venous occlusions in the IAAVG group (16.3% vs
6.8%; P < .04). Of the IAAVG group, 50 were Acuseal (W. L. Gore & Associates, Flagstaff, Ariz) and 12 were Flixene (Atrium
Medical Corporation, Hudson, NH). Primary patency was similar at both 1 year (SAVG, 39.4%; IAAVG, 56.7%; P ¼ .4) and
18 months (SAVG, 29.0%; IAAVG, 43.7%; P ¼ .4). Secondary patency was similar at 1 year (SAVG, 50.7%; IAAVG, 52.1%; P ¼ .73)
and 18 months (SAVG, 42.3%; IAAVG, 46.3%; P ¼ .73). Overall survival was 48% at 24 months. IAAVG patients required fewer
overall additional procedures to maintain patency (mean number of procedures, 0.99 for SAVGs vs 0.61 for IAAVGs;
P ¼ .025). There was no difference in occurrence of steal syndrome (SAVG, 6.8%; IAAVG, 8.1%; P ¼ .74) or graft infection
(SAVG, 19.0%; IAAVG, 12.0%; P ¼ .276). Seventy-five percent of all grafts were successfully cannulated, with shorter median
time to first cannulation in the IAAVG group (6 days; interquartile range [IQR], 1-19 days) compared with the SAVG group
(31 days; IQR, 26-47 days; P < .01). Of all pre-existing catheters, 65.75% were removed, with a shorter median time until
catheter removal in the IAAVG cohort at 34 days (IQR, 22-50 days) vs 49 days (IQR, 39-67 days) in the SAVG group (P < .01).
Catheter-related complications occurred less frequently in the IAAVG group (16.4% vs 2.9%; P < .045).
Conclusions: IAAVGs allow earlier cannulation and tunneled catheter removal, thereby significantly decreasing catheter-
related complications. Patency and infection rates were similar between SAVGs and IAAVGs, but fewer secondary
procedures were performed in IAAVGs. (J Vasc Surg 2018;-:1-7.)
Keywords: Acuseal; Arteriovenous graft; Immediate-access graft; Dialysis catheter; Catheter infection; Flixene

For decades, arteriovenous fistulas (AVFs) have been
the favored access modality for patients reliant on hemo-
dialysis (HD). This trend was bolstered in 2006 by the
release of the National Kidney Foundation’s Kidney
Disease Outcomes Quality Initiative guidelines, with
companion publication of synonymous clinical practice
guidelines by the Society for Vascular Surgery.1,2 Arterio-
venous grafts (AVGs) are considered a second-line access
modality in comparison to AVFs. This is largely due to the
AVG’s inferior patency rates and frequent reinterventions.

From the Division of Vascular Surgery, University of Pittsburgh Medical Center,
Pittsburgha; and the Division of Vascular Surgery, Duke University Medical
Center, Durham.b
Author conflict of interest: none.
Presented at the 2017 Annual Meeting of the Society for Vascular Surgery, San
Diego, Calif, May 31-June 3, 2017.
Correspondence: Jason K. Wagner, MD, MSc, Vascular Surgery, University of
Pittsburgh, UPMC HVI, 200 Lothrop St, Pittsburgh, PA 15232 (e-mail:
wagnerjk@upmc.edu).
The editors and reviewers of this article have no relevant financial rela-
tionships to disclose per the JVS policy that requires reviewers to
decline review of any manuscript for which they may have a conflict
of interest.
0741-5214
Copyright Ó 2018 by the Society for Vascular Surgery. Published by Elsevier Inc.
All rights reserved.
https://doi.org/10.1016/j.jvs.2018.06.204

1
2 Wagner et al
Tunneled dialysis catheters (TDCs) serve as a “last-resort”
means of access yet account for >75% of initial HD
access in the United States.3
AVGs have a growing acceptance as an incident access
modality in patients with inadequate superficial venous
anatomy or limited life expectancy.4,5 For all patients,
regardless of their access type, if they are already HD
dependent, any period between access creation and
successful cannulation will require a TDC, with its associ-
ated risks: induction of central venous stenosis and
infection.
Early cannulation of standard AVGs (SAVGs), using
small-bore needles, diligent antisepsis, and attentive
pressure for hemostasis, dates to the 1990s, with reports
of improved postcannulation hemostasis with some of
the first iterations of immediate-access AVGs (IAAVGs).6
These IAAVGs have become increasingly available in
the last decade. Numerous industry-driven noncompara-
tive studies have shown patency rates comparable to
those in published literature for SAVGs but with the
claimed additional benefit of shorter interval periods of
catheter dependence.7 Although encouraging, the
short-term results of these prospective, single-arm
clinical trials of the current, commercially available
IAAVGs do not represent independent experience with
12- to 18-month outcomes of these grafts’ performance
in the heterogeneous treatment setting of the United
States. Furthermore, these studies do not offer a “same-
center”’ comparison of IAAVGs with SAVGs in a practical
setting.
The goal of this project was to provide “real-world” com-
parison of performance and midterm outcomes of
IAAVGs and SAVGs at two major tertiary centers in the
United States.
METHODS
This study is a two-institution retrospective review of 210
consecutive attempts at AVG implantation between
November 2014 and April 2016. At the two participating
centers, SAVGs were procured from Gore (W. L. Gore &
Associates, Flagstaff, Ariz). At these centers, two types of
IAAVG have been incorporated into clinical practice:
Acuseal (Gore) and Flixene (Atrium Medical Corporation,
Hudson, NH). All grafts are commercially available, and
none of the procedures were performed as part of an
industry-funded trial.
After Institutional Review Board approval was obtained
for waived informed consent at both institutions, consec-
utive patients who underwent placement of an AVG for
HD access between November 2014 and April 2016
were retrospectively identified from the electronic
medical record and the Vascular Quality Initiative data-
base. Only grafts with direct arterial inflow and venous
outflow were included for analysis. Interposition graft
placements were excluded from analysis. Patients were
divided into two groups based on the type of graft
Journal of Vascular Surgery
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ARTICLE HIGHLIGHTS
d
Type of Research: Retrospective cohort study
d
Take Home Message: Eighteen-month patency and
infection rates were similar between 148 standard
and 62 immediate-access arteriovenous grafts, but
immediate-access grafts had fewer secondary pro-
cedures and allowed earlier cannulation and
tunneled catheter removal, thereby significantly
decreasing catheter-related complications.
d
Recommendation: These data support preferential
use of immediate-access arteriovenous grafts.
implanted (SAVG and IAAVG). Patients’ comorbidities,
graft configuration, operative characteristics, and subse-
quent follow-up were collected and analyzed with
respect to primary and secondary patency. Additional
outcomes included graft-related complications, time to
first cannulation, time to tunneled catheter removal,
catheter-related complications (thrombosis or infection,
requiring replacement), and overall survival.
Surgeons within the two vascular surgery divisions
(cumulatively, 21 surgeons) at the respective institutions,
whose practices include a large proportion of HD access
work, performed the procedures. In the early experience
at both institutions, IAAVGs were reserved for patients
with an urgent need for a durable HD access who lacked
appropriate venous anatomy that would warrant the
creation of a fistula or placement of an SAVG and simulta-
neous placement of an interval TDC. Later, some surgeons
at each center began to transition toward using IAAVGs as
their default conduit for nonautogenous access.
Patency was defined per Society for Vascular Surgery
recommended reporting standards and was determined
from the time of the index procedure.8 Follow-up infor-
mation was obtained through review of inpatient and
outpatient records as well as external dialysis center
records, when available.
Statistical analysis. Categorical data are described with
counts and proportions and continuous data with
means, ranges, and standard deviations. Patency rates
were analyzed using life-table analysis, and patency
rate comparisons were made with a two-group propor-
tion comparison calculator with the P value set as
significant at < .05. All analysis was performed using
Stata 14 software (StataCorp LP, College Station, Tex).
RESULTS
During the study period, 210 grafts meeting inclusion
criteria were implanted. Of these, 148 grafts were SAVGs
and 62 were IAAVGs. Most IAAVGs were Acuseal (81%)
and 12 were Flixene (28%). Demographics and comorbid-
ities were consistent with U.S. Renal Data System national
sample characteristics during this study period (Table I).
Journal of Vascular Surgery Wagner et al 3
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Table I. Demographics Table II. Graft configurations

Variable (N ¼ 210) SAVG (n ¼ 148) IAAVG (n ¼ 62) P Overall SAVG IAAVG P
Age, years 63.6 (22.8-90.5) 60.7 (18.5-89.8) .21 Forearm loop 88 (44.7) 67 (48.2) 21 (36.2) .12
Male 61 (41.5) 34 (54.8) .08 Upper arm straight 109 (55.3) 72 (51.8) 37 (63.8) .12
Black 88 (59.9) 35 (57.4) .74 Femoral 13 (6.2) 9 (6.1) 4 (6.5) .92
BMI, kg/m2 30.3 (16.0-63.9) 27.9 (15.0-51.9) .07 Tapered 36 (17.6) 27 (18.9) 9 (14.5) .45
Diabetes 63 (57.3) 24 (63.2) .53 IAAVG, Immediate-access arteriovenous graft; SAVG, standard arterio-
venous graft.
Hypertension 140 (94.6) 56 (91.8) .45
Values are reported as number (%).
Tobacco use 28 (18.9) 10 (16.3) .63
HD dependent 135 (91.2) 60 (96.8) .15
At 1 year, there were no significant differences with
History of central 10 (6.8) 9 (16.3) .04
venous occlusion respect to primary patency (SAVG, 39.4%; IAAVG, 56.7%;
Prior accesses 1.48 (0-8) 1.71 (0-6) .53 P ¼ .4) or secondary patency (SAVG, 50.7%; IAAVG,
52.1%; P ¼ .73). Similarly, there were no significant differ-
Prevalent TDC 127 (89.6) 42 (70.0) .01
ences in primary patency (SAVG, 29.0%; IAAVG, 43.7%;
BMI, Body mass index; HD, hemodialysis; IAAVG, immediate-access
arteriovenous graft; SAVG, standard arteriovenous graft; TDC, P ¼ .4) or secondary patency (SAVG, 42.3%; IAAVG,
tunneled dialysis catheter. 46.3%; P ¼ .73) at 18 months (Figs 2 and 3).
Categorical variables are presented as number (%). Continuous vari-
ables are presented as mean (range). Seventy-five percent of all grafts were successfully
accessed, with comparable rates in each group (SAVG,
73.1%; IAAVG, 80.1%; P ¼ .25). The most common reason
The two patient cohorts were largely similar, with >91% for documented nonuse was death before follow-up
of patients in both groups being HD dependent at the and lack of confirmation that the graft was used. In
time of the index surgery. Most patients had diabetes others, the graft thrombosed before any documented
mellitus, hypertension, and chronic obstructive pulmo- cannulation, and there was no attempt to salvage it
nary disease. Notably, there was a significantly greater (a new access was placed). There was a significantly
prevalence of prior interventions for or radiographic shorter median time to first cannulation in the IAAVG
evidence of central vein outflow obstruction in the IAAVG group (6 days; interquartile range [IQR], 1-19 days)
cohort. The mean number of prior accesses was compa- compared with the SAVG group (31 days; IQR,
rable between the groups; however, there was a signifi- 26-47 days; P < .01). A large proportion (45%) of IAAVGs
cantly larger proportion of patients in the SAVG group were accessed within 72 hours of placement. There
with prevalent catheters at the time of graft placement were no instances of bleeding or infection attributable
(82% overall; SAVG, 87.6%; IAAVG, 70%; P < .01). to early cannulation (within 10 days of graft placement).
The majority of grafts were of a straight, upper arm With regard to catheter removal, 65% of tunneled cathe-
configuration (Table II), with no difference between the ters were removed, and although no difference was iden-
two groups (55.3% overall; SAVG, 51.8%; IAAVG, 63.8%; tified with respect to the rate of catheter removal (SAVG,
P ¼ .12). The majority of upper extremity grafts in each 64.7%; IAAVG, 65.9%; P ¼ .89), the median time until
group derived their inflow from the brachial artery catheter removal was significantly shorter in the IAAVG
(85.3% overall; SAVG, 83.5%; IAAVG, 89.7%; P ¼ .55). cohort at 34 days (IQR, 22-50 days) vs 49 days (IQR,
Technical success for access creation was 100%. Eleven 39-67 days) in the SAVG group (P < .01). Catheter-
(5.2%) patients died within a month of the operation, all related complications were significantly lower in the
of causes thought to be unrelated to the procedure, with IAAVG group (SAVG, 16.4%; IAAVG, 2.9%; P ¼ .04). The
no significant difference between the two groups (SAVG, IAAVG cohort required significantly fewer procedures
5.4%; IAAVG, 4.8%; P ¼ .87). There were 15 cases (7.1%) of (0.61 6 0.8 per access vs 0.99 6 1.4 per access; P ¼ .03)
steal syndrome requiring surgical intervention, with no to achieve the aforementioned comparable patency
difference between the two groups (SAVG, 6.8%; IAAVG, rates throughout the overall follow-up interval
8.1%; P ¼ .74). During follow-up, 26 (16.8%) graft infections (Tables III and IV).
were identified, 2 of which were early (within 30 days).
Both of these were in the SAVG group. No significant DISCUSSION
difference in overall infection rates was identified Our retrospective review of prospectively obtained data
(SAVG, 19.1%; IAAVG, 12%; P ¼ .27). serves as one of the largest independent comparisons
Mean follow-up time was 9.8 6 8.7 months, with no between SAVGs and IAAVGs. Our study demonstrated a
difference between the two groups (SAVG, 10.5 6 consistent ability to successfully cannulate IAAVGs in
8.9 months; IAAVG, 8.0 6 7.8 months; P ¼ .09). Overall sur- the immediate perioperative setting without bleeding
vival was 48.1% at 24 months, with no difference between complications or infection. Notably, our series finds
the two groups (SAVG, 51.6%; IAAVG, 37.8%; P ¼ .32; Fig 1). comparable patency rates between the two graft types,
4 Wagner et al
Fig 1. Overall survival. All standard error through
24 months is <10%.
Fig 2. Primary patency (P ¼ .41). All standard error through
18 months is #10%. IAAVG, Immediate-access arteriove-
nous graft; SAVG, standard arteriovenous graft.
with lower rates of reintervention in the IAAVG cohort.
We also found that patients who underwent placement
of an IAAVG had the graft cannulated sooner, had earlier
catheter removal, and had fewer catheter-related
complications.
The first published series of early-cannulation graft
implantation were described in the 1980s; however, this
technology’s entry into extensive clinical practice has
Journal of Vascular Surgery
--- 2018
Fig 3. Secondary patency (P ¼ .73). All standard error
through 18 months is #10%. IAAVG, Immediate-access
arteriovenous graft; SAVG, standard arteriovenous graft.
only really occurred in the past 10 to 15 years. The first
widely used early-cannulation access was the Vectra tri-
layer graft (C. R. Bard, Murray Hill, NJ). Initial analyses
did not identify any additional benefit over standard
expanded polytetrafluoroethylene grafts.9 Subsequent
published series demonstrated long-term secondary
patency rates comparable to those of brachiobasilic
AVFs, but with significantly greater rates of reintervention
with the Vectra graft.9,10 The Flixene vascular graft has
been Food and Drug Administration approved and
available for use in the United States for the past 12 years.
Per instructions for use, this graft can initially be accessed
72 hours after implantation. The Gore Acuseal vascular
graft is the most recent entry into the marketplace of
IAAVGs (2013). Like the Vectra and Flixene grafts, the
Acuseal is an expanded polytetrafluoroethylene trilayer
graft; however, the Acuseal is unique in that its inner
lumen is also coated with a layer of covalently bound
heparin, and the graft can be accessed within 24 hours
of implantation.
The Acuseal graft represented the majority of the
IAAVGs implanted in our series. Few Acuseal-centric
studies exist in the peer-reviewed literature. In those
identified, there is significant heterogeneity of results
regarding the number of grafts implanted, indications
for placement, patency rates, and duration of follow-
up.11,12 In the independent European series of 55 Acuseal
grafts of Maytham et al,13 1-year results were notable for
12-month primary patency of 46% and secondary
patency of 61%, with 73% of patients being cannulated
Journal of Vascular Surgery Wagner et al 5
Volume -, Number -

Table III. Clinical outcomes criteria similar to those of our study, and it is the largest
SAVG IAAVG P identifiable comparison of SAVGs and IAAVGs outside
of our series. Their sample was composed of 78 SAVGs
Follow-up, months 10.5 (0.2-32.7) 8.0 (0.1-31.7) .09
and 44 IAAVGs, with significant heterogeneity of IAAVGs
Perioperative deaths 8 (5.4) 3 (4.8) .87
implanted (3 Vectra, 18 Flixene, and 23 Acuseal). They
Steal syndrome 10 (6.8) 5 (8.1) .74
found comparable patency rates between the SAVGs
AVG infection 20 (19.1) 6 (12.0) .27 and IAAVGs, with no differences in reintervention rates.
AVG use 103 (73.1) 50 (80.1) .25 The higher rates of reintervention in their IAAVG sample
AVG, Arteriovenous graft; IAAVG, immediate-access arteriovenous graft; can possibly be attributed to their inclusion of Vectra
SAVG, standard arteriovenous graft.
Categorical variables are presented as number (%). Continuous vari- grafts, with their aforementioned documented higher
ables are presented as mean (range). reintervention rates. The finding of the group from
Eastern Virginia Medical School of no reduction in cath-
eter dwell times in the IAAVG group could be related
Table IV. Graft maturation and catheter-related
complications to their earlier period of study, when IAAVGs were less
prevalent and targeted postoperative management
SAVG IAAVG P
and early cannulation were not yet pervasive, as was
Maturation, days 31 (26-47) 6 (1-19) .00 seen in our early experience. The 1-year secondary
Catheter removal 66 (64.7) 29 (65.9) .89 patency rate in their IAAVG sample (54%) is similar to
Catheter, days 49 (39-67) 34 (22-50) .00 that found in our series (52.1%).
TDC complications 12 (16.4) 1 (2.9) .04 In 2017, Aitken et al17 reported on the use of IAAVGs
Reinterventions 0.99 (0-7) 0.61 (0-3) .03 in place of TDCs as a means for urgent HD access. In
IAAVG, Immediate-access arteriovenous graft; SAVG, standard arterio- their randomized trial, IAAVGs were associated with
venous graft; TDC, tunneled dialysis catheter. significantly fewer infectious complications compared
Categorical variables are presented as number (%). Continuous vari-
ables are presented as median (interquartile range). with TDCs.15 In their series, they found cost equivalence
between the two accesses because the expenses of
infectious complications in the TDC arm balanced
within 24 hours of graft placement. The largest prospec- initial surgical expenditures in the IAAVG arm.15
tive series (138 grafts) was published by Glickman et al14 Although cost was not an end point in our study, the
in 2015 and reported primary and secondary graft IAAVG cohort does have a significantly lower rate of
patency at 12 months of 33% and 78%, respectively. infectious complications (12%) compared with historical
In comparing the results of our IAAVG cohort with controls of TDC use, therein supporting the notion that
the independent European series, there is congruity; such cost equivalence could also apply in this popula-
however, compared with the 1-year results of the tion of patients.18,19
industry-supported trial of Glickman et al, the primary With regard to TDC-related complications, our study’s
patency results are comparable, yet there was a signifi- results show that graft type can be associated with
cant disparity in the cumulative patency and the total decreased rates of untoward catheter-associated events.
number of reinterventions. The study of Glickman et al The meaningfully lower rate of TDC infections and
claims a cumulative patency rate of 79% but with a thromboses in our series’ IAAVG cohort was not surpris-
larger number of reinterventions (1.6 per access) to ing, given the significantly shorter catheter dwell times
achieve this outcome. By comparison, the patients in for those who underwent graft placement with an exist-
our series with Acuseal grafts underwent an average of ing TDC. The reduction in catheter days in the IAAVG
0.57 6 0.79 procedures per access. cohort is not surprising, but also the potential benefits
In comparison to recent industry trials, there is a notable of reduced catheter days were not fully realized on ac-
discrepancy in our 1-year survival rate. At 12 months, the count of variations in practice patterns and the evolving
overall survival rate of 57.9% in our IAAVG cohort is signifi- pervasive use of IAAVGs at our two centers. The approach
cantly lower than that reported by the Acuseal series of to assessing catheter removal after graft placement was
Glickman et al (87.7%) but is comparable to outcomes conservative, using the first date of documented (radio-
identified in the U.S. Renal Data System.15 We attribute graphic or clinical records) evidence of catheter absence
this difference to our heterogeneous sample of patients, as a surrogate date for catheter removal when no specific
many of whom were “end-stage dialysis patients” and documentation of catheter removal could be evidenced.
not just entering a state of end-stage renal disease with This in turn has likely led to an overestimation of catheter
new HD dependence. dwell time in this series.
The group from Eastern Virginia Medical School Despite 45% of all IAAVGs being accessed within 3 days
recently reported on their experience with IAAVGs and of placement, an overall median catheter dwell time
compared them with their SAVG cases.16 They reviewed around 1 month is indicative of a disconnect in the
a 14-month experience from 2011 to 2012, with exclusion outpatient setting during the postoperative period. Early
6 Wagner et al
in this series, because of lack of experience with these
novel trilayer grafts, HD unit nurses and their supervising
nephrologists were treating these grafts no differently
from the SAVGs to which they had become accustomed.
Recently, and in large part because of this analysis, a
targeted postoperative management plan has been
developed that involves communication with the HD
unit and early clinic follow-up and TDC removal. This
should lead to a dramatic reduction in the catheter
dwell times for those with functional IAAVGs.
This project does have its limitations, namely, its retro-
spective nature combined with a heterogeneous sample
of patients. Therefore, any comparisons between graft
types or generalizations of experience might not neces-
sarily translate to a larger population. Notably, the expe-
rience in this series is drawn from a tertiary care setting
and might vary from that of community practices with
established access creation and management pathways.
This project does not directly evaluate the cost-
effectiveness of the grafts being reviewed, nor does it
include an analysis of bovine carotid grafts, which are
an alternative to IAAVGs and SAVGs. Further indepen-
dent, multicenter, randomized prospective study of the
performance of IAAVGs and SAVGs would further discern
any advantages or pitfalls of this novel technology in the
creation of durable HD accesses.
CONCLUSIONS
Real-world experience with immediate-use arteriove-
nous access grafts is consistent with results from
industry-sponsored studies and is not inferior to the
results of SAVGs. Compared with SAVGs, IAAVGs offer
comparable patency, with reduced interval catheter
dwell times as well as reduced rates of catheter-
associated complications. Although early cannulation of
immediate-access grafts can be successfully placed in a
wide variety of patients, without any increased risk of
ischemic steal, bleeding events, or infection, prolonged
catheter dwell times can still persist in actual practice.
Further study of focused efforts toward establishing
protocols for close follow-up, early cannulation, and
subsequent catheter removal in those undergoing
IAAVG implantation is warranted.
AUTHOR CONTRIBUTIONS
Conception and design: JW, ED, RC, TY, MM, EA
Analysis and interpretation: JW, ED, EH, EA
Data collection: JW, UN, AA, ST, TY, MM
Writing the article: JW
Critical revision of the article: JW, ED, UN, AA, ST, RC, EH,
TY, MM, EA
Final approval of the article: JW, ED, UN, AA, ST, RC, EH,
TY, MM, EA
Statistical analysis: JW, EA
Obtained funding: Not applicable
Overall responsibility: JW
Journal of Vascular Surgery
--- 2018
REFERENCES
1. National Kidney Foundation’s KDOQI 2006 vascular access
guidelines. Am J Kidney Dis 2006;48:S177-322.
2. Sidawy AN, Spergel LM, Besarab A, Allon M, Jennings WC,
Padberg FT Jr, et al. The Society for Vascular Surgery: clinical
practice guidelines for the surgical placement and mainte-
nance of arteriovenous hemodialysis access. J Vasc Surg
2008;48(Suppl):2S-25S.
3. United States Renal Data System (USRDS). USRDS 2012
annual data report: atlas of end-stage renal disease in the
United States. Bethesda, Md: National Institutes of Health,
National Institute of Diabetes and Digestive and Kidney
Diseases; 2012. Available at: http://www.usrds.org/atlas12.
aspx. Accessed June 25, 2016.
4. Lee HW, Allon M. When should a patient receive an arte-
riovenous graft rather than a fistula? Semin Dial 2013;26:
6-10.
5. Leake AE, Yuo TH, Wu T, Fish L, Dillavou ED, Chaer RA, et al.
Arteriovenous grafts are associated with earlier catheter
removal and fewer catheter days in the United States Renal
Data System population. J Vasc Surg 2015;62:123-7.
6. Hudson PC. Early cannulation of vascular access sites for
dialysis. Dial Transplant 1996;25:523-6.
7. Al Shakarchi J, Houston G, Inston N. Early cannulation grafts
for haemodialysis: a systematic review. J Vasc Access 2015;16:
493-7.
8. Sidawy AN, Gray R, Besarab A, Henry M, Ascher E, Silva M,
et al. Recommended standards for reports dealing with
arteriovenous hemodialysis accesses. J Vasc Surg 2002;35:
603-10.
9. Kakkos SK, Topalidis D, Haddad R, Shepard AD. Long-term
complication and patency rates of Vectra and IMPRA Car-
boflo vascular access grafts with aggressive monitoring,
surveillance and endovascular management. Vascular
2011;19:21-8.
10. Kakkos SK, Andrzejewski T, Haddad JA, Haddad GK,
Reddy DJ, Nypaver TJ, et al. Equivalent secondary patency
rates of upper extremity Vectra Vascular Access Grafts and
transposed brachial-basilic fistulas with aggressive access
surveillance and endovascular treatment. J Vasc Surg
2008;47:407-14.
11. Tozzi M, Franchin M, Letto G, Soldini G, Carcano G, Castelli P,
et al. Initial experience with the Gore Acuseal graft for
prosthetic vascular access. J Vasc Access 2014;12:385-90.
12. Aitken EL, Jackson AJ, Kingsmore DB. Early cannulation
prosthetic graft (Acuseal) for arteriovenous access: a useful
option to provide a personal vascular access solution. J Vasc
Access 2014;15:481-5.
13. Maytham GG, Srahn HK, Chemla ES. The use of the early
cannulation prosthetic graft (Acuseal) for angioaccess for
haemodialysis. J Vasc Access 2015;16:467-71.
14. Glickman MH, Burgess J, Cull D, Roy-Chaudhury P,
Schanzer H. Prospective multicenter study with a 1-year
analysis of a new vascular graft used for early cannulation in
patients undergoing hemodialysis. J Vasc Surg 2015;62:
434-41.
15. Lok CE, Foley R. Vascular access morbidity and mortality:
trends of the last decade. Clin J Am Soc Nephrol 2013;8:
1213-9.
16. Steerman S, Dexter D, Ahanchi S, Stokes G, Ongstad S,
Powell O, et al. Early-access upper extremity grafts offer no
benefit over standard grafts in hemodialysis access. J Vasc
Surg 2017;65:e6.
17. Aitken E, Thomson P, Bainbridge L, Kasthuri R, Mohr B,
Kingsmore D. A randomized controlled trial and cost-
effectiveness analysis of early cannulation arteriovenous
grafts versus tunneled central venous catheters in patients
Journal of Vascular Surgery
Volume -, Number -
requiring urgent vascular access for hemodialysis. J Vasc
Surg 2017;65:766-74.
18. Thomson PC, Stirling CM, Geddes CC, Morris ST,
Mactier RA. Vascular access in haemodialysis patients: a
modifiable risk factor for bacteraemia and death. QJM
2007;100:415-22.
DISCUSSION
Dr Fedor Lurie (Toledo, Ohio). You have identified sig-
nificant differences between those two groups in this
retrospective study. Do those differences reflect partici-
pating physicians’ preferences, institutional protocols, or
both? How much did these differences influence the
study outcomes?
Dr Jason K. Wagner. Overall patient-specific factors
were very similar between the two groups. If the question
is, Are you using the immediate-access grafts more for
access of last resort? Then yes, with some of the Flixene
grafts (about half of them, so maybe six), that was kind
of the case. But when we looked at a subgroup analysis,
even though it was a really small sample, we really
couldn’t find any differences between that. Some of
the providers are now starting to move toward using
the immediate-access graft as their standard graft of
use. But we’re not placing these in the setting of delayed
planning for initiating dialysis down the road; these are
being placed at the time of need.
Dr John Blebea (Saginaw, Mich). The entire argument
for immediate access grafts is that they can be
implanted and utilized urgently, without the need for
tunneled catheters. However, in your own data, there
was not a large difference in terms of the duration of
catheter use. The median time was approximately
32 days vs 40 days for the standard grafts. In addition,
all of the patients implanted with immediate access
grafts had at least 3 weeks of catheter use. Therefore,
the entire argument of having these grafts immediately
available 24 hours later was never actually employed.
So did it really clinically make any difference?
Dr Wagner. That’s a great point. In actuality, we’ve
changed our practice pattern now so when we’re
placing immediate access grafts in our patients,
we’re notifying the patient that this graft can be
accessed right away. We’re contacting the dialysis cen-
ter, the treating nephrologist, and we move up our
follow-up period to be removing that catheter closer
to a 1-week to 2-week period of time, after three to
five successful cannulations, rather than waiting until
1-month follow-up. So we’ve actually started to kind
of do a practice pattern shift with that and hopefully
look to present those quality improvement results
down the road.
Wagner et al 7
19. Taylor G, Gravel D, Johnston L, Embil J, Holton D, Paton S.
Prospective surveillance for primary bloodstream infections
occurring in Canadian hemodialysis units. Infect Control
Hosp Epidemiol 2002;23:716-20.
Submitted Apr 5, 2018; accepted Jun 25, 2018.
Dr Patrick Ryan (Nashville, Tenn). It’s a great study. I’ve
got some experience with the Flixene graft myself. I don’t
use it anymore. I have two questions.
You had a 20% infection rate on the Gore grafts and
10-ish percent infection rate on the Flixene, I believe.
That seems high. What do you do with an infected graft?
I take it out. What do you do?
Dr Wagner. Right. So the two groups were standard
graft, just a normal, in this case Gore, like a Propaten or
standard stretch wall, vs the immediate-access group,
which is also mostly in that case Gore.
With regard to management of the infection, usually
interposition if you can interpose around a focal area of
an infected graft. Often we’re using immediate-access
graft as an interposition. But if it’s just grossly infected or
at an anastomosis or something like that and you can’t
have a stickable segment, then we’ll just explant, go to a
catheter, either temporary or tunnel, depending on how
systemically sick they are, and then plan for another access
in the very near term, usually during that admission.
Dr Ryan. So all of the 19% of the regular arteriovenous
graftsdwere they counted as revisions in your statistics,
or how?
Dr Wagner. No, we were actually d
Dr Ryan. Were they secondary patency? What did you
do with them?
Dr Wagner. So if someone had an infection, we consider
that graft explanted and we removed that from the study.
So it almost artificially kind of gives it a lower patency rate.
Dr Ryan. And to my experience with the Vectra is that
when you put it in the patient’s skin, the patients don’t
tolerate it well, it hurts. I have put in about 10 of them
and quit. Have you had like a dense inflammation
around this graft, have you had any experience like that?
Dr Wagner. I have never touched a Vectra graft, so I
can’t speak to that.
Dr Anil Hingorani (Brooklyn, NY). Just two short ques-
tions. What about the cost of the device? And did you
mention where you placed these grafts? Was it in the
forearm or the upper arm? Was there a difference be-
tween the two data sets?
Dr Wagner. All the same. All were upper arm. Actually,
there were a couple that were lower extremity; most
were upper arm straight configuration.