Leigh Anne Dageforde, MD, MPH,

Kelly A. Harms, BA,

Irene D. Feurer, PhD
and
David Shaffer, MD, FACS
INTRODUCTION
 Autogenous arteriovenous hemodialysis
accesses/ arteriovenous fistulas (AVFs)
preferred vascular access for
chronic hemodialysis
 Higher patency rates
 Reduced complications
 Reduced costs
 NKF-KDOQI (Fistula First Breakthrough
Initiative) → preoperative duplex
ultrasound as the standard of care
before placement AVF
 Recent single-center studies report a
primary AVF failure rate of 26% to 50%
→ primary 1-year patency rate of 36% to
46%
 Multicenter Dialysis Access Consortium
study → 60% of AVFs failed to mature.
 Some experts suggest a vein diameter
of 2.5 mm as adequate for AVF creation
 One study that did include preoperative
vein diameter as a predictor of fistula
maturation used a threshold vein
diameter of >4 mm
 The aim of this study was to
 Test after adjustment for clinical factors
 Long term patency in patients.
METHODS
 Retrospective review of new AVF access
creation from February 2009 to June
2011 by one of three surgeons
 The selection criteria for type of
arteriovenous access followed KDOQI
and Society for Vascular Surgery
guidelines
 Radiocephalic Brachiobasilic
 Brachiocephalic Prosthetic graft
 This study exclude :
 Patients younger than 18 years without
preoperative vein mapping
 Fistula for intermittent plasmapheresis
 Patients who underwent placement of a
radiocephalic fistula
 This study do not include :
 Presence or absence of central venous
stenosis
 Patients with a prior failed fistula or graft
 AVF revisions
 Minimum vein diameter (MVD) was
determined from the results of preoperative
duplex ultrasound → Intersocietal
Accreditation Commission-accredited
vascular ultrasound laboratory
 Measurements of maximum axis of vein
lumen diameter were made by the vascular
ultrasound technicians: antecubital fossa,
distal, midpoint, and proximal
 The duplex ultrasound
examination was performed
without a tourniquet by a
Philips iU22 ultrasound
machine (Philips, Bothell,
Wash) with a high-frequency
(5- 9 MHz) linear probe
Definition
 Fistula maturation was defined as at
least one successful use of the fistula
with two needles for dialysis after a
clinical determination by the operating
surgeon and dialysis technician
 Long-term or secondary patency was
defined as the time to fistula
abandonment and could include open
or percutaneous interventions to
maintain patency.
Analysis
 Statistical analyses were performed with
SPSS Statistics V21
 Univariate Kaplan-Meier survival
analysis with log-rank tests
RESULTS
 Between February 2009 and June 2011,
278 new arteriovenous accesses (194
AVFs (70%), 84 prosthetic grafts (30%))
were placed by one of three surgeons
 194 patients who had an AVF placed,
36 were excluded from further analysis
for not
 having vein mapping on chart review (n ¼
17)
 having a radiocephalic fistula (n ¼ 14)
 being younger than 18 years (n ¼ 1)
 having a fistula placed for plasmapheresis (n
¼ 4)
 32 patients (20%) had the fistula fail
before use because of either failure to
mature (n ¼ 13) or thrombosis (n ¼ 19).
 Other causes of nonuse for dialysis
included
 ligation for steal (n ¼ 8)
 death before use (n ¼ 10)
 transplantation before use (n ¼ 4)
 20 patients (13%), the patient was not
yet on dialysis at the time of loss to
follow-up.
 Consequently, 84 (53%) of patients’
fistulas were ultimately used for dialysis
during the study period
 Vein diameter data were normally
distributed with a mean of 3.4 + 1.1 mm
 MVD quartiles were defined for
 quartile 1, <2.7 mm
 quartile 2, 2.7 to 3.2 mm
 quartile 3, 3.3 to 4.1 mm
 quartile 4, >4.1 mm
 Kaplan-Meier analysis indicated that
increased MVD was associated with
decreased risk of failure to mature,
which is synonymous with an increased
likelihood of fistula maturation
 Fistulas with a vein diameter in the
upper two quartiles (MVD > 3.3 mm)
had significantly greater likelihood of
fistula maturation than did fistulas in the
lowest quartile (MVD <2.7 mm).
 More than one third of AVFs with MVD
<2.7 mm failed to mature by 6 months.
 Model of long-term patency, the fistulas
in the upper two quartiles (MVD > 3.3
mm) had a significantly higher
likelihood of long-term survival
compared with the fistulas in the lowest
quartile (MVD <2.7 mm)
 AVFs with MVD <2.7 mm were associated
with a higher risk of failure of maturation and
a lower long-term patency than were AVFs
with MVD > 3.3 mm
Multivariate Analysis
 Multivariate Cox regression models
were used to analyze associations of
demographic and clinical covariates
 Age, sex, race, preoperative dialysis
status, and BMI were not statistically
significant in any of the multivariate
models
 Having CAD was significantly
associated with a decreased overall risk
of fistula failure (P ¼ .039)
 Preoperative dialysis was associated
with increased risk of fistula failure (P ¼
.022)
DISCUSSION
 Duplex ultrasound examination has been
found to be accurate compared with
intraoperative findings of vein diameter
 This study is also unique because the
cohort included
 patients with prior tunneled dialysis catheters
and
 prior arteriovenous access procedures as well
as patients undergoing initial placement of an
AVF
 This study tested whether preoperative
clinical covariates were associated with
fistula maturation or long-term patency.
 CAD was significantly associated with
a decreased risk of long-term fistula
failure but not with failure of fistula
maturation.
 Association between CAD and a
decreased risk of failure in the long-term
patency model may be secondary to the
use of antiplatelet medications
 CAD as defined in this study are more
likely to be receiving antiplatelet
therapy to promote patency of cardiac
stents or vessels
 Patients in our study with CAD may
have had better long-term patency
because of the use of antiplatelet
medications
 Patient medication regimens were not
reviewed for this study
 Being on dialysis before fistula
placement was associated with
improved long-term patency but not
with fistula maturation.
Limitation
• First, this is a retrospective review, so
the determination of the placement of
the fistula in a particular location was
made by clinical judgment of the
operating surgeon.
• Second, this was a retrospective
study, so information such as flow
rate, Kt/V,and needle size
requirements to determine the
adequacy of the access for dialysis
are not available
 Third, there may be considerable day-to-
day variability in vein diameters,
depending on the patient’s hydration,
type of anesthesia used, and technique
(eg, use of tourniquet or not) or different
vascular technologists.
RESULTS
 Results from the univariate Kaplan-
Meier and multivariate Cox regression
models consistently indicate that a
reduced vein diameter is associated with
increased risk of an adverse outcome
CONCLUSIONS
 Patients with a larger vein diameter on
preoperative vein mapping are at lower
risk for failure of fistula maturation and
have increased long-term AVF patency
 Duplexultrasound should be used to
determine the MVD of the vein for
potential future fistula operations
 MVD was the only clinical or
demographic factor associated with both
AVF maturation and long-term patency
THANK YOU...