Outcomes of arteriovenous fistula creation after the Fistula First Initiative

Abstract

Background and objectives: The arteriovenous fistula (AVF) is the preferred hemodialysis access, but AVF-failure rate is high, and complications from AVF placement are rarely reported. There is no clear consensus on predictors of AVF patency. This study determined AVF outcomes and patency predictors at Mayo Clinic Rochester following the Fistula First Initiative.

Design, setting, participants, & measurements: A retrospective cohort study of AVFs placed at Mayo Clinic from January 2006 through December 2008 was performed. The AVF placement-associated primary and secondary failure rates, complications, interventions, and hospitalizations were examined. Kaplan-Meier survival curves and Cox proportional hazard models were used to determine primary and secondary patency and associated predictors.

Results: During this time frame, 317 AVFs were placed in 293 individual patients. The primary failure rate was 37.1% after excluding patients not initiated on hemodialysis during follow-up (n = 38) or those with indeterminate outcome (37 lost to follow-up; six died; two transplanted). Of usable AVFs, 11.4% later failed. AVF creation incurred complications and hospitalization in 21.2% and 12.3% of patients, respectively. The risk for reduced primary patency was increased by diabetes (HR, 1.54; 95% CI, 1.14 to 2.07); the risk for reduced primary and secondary patency was decreased with larger arteries (HR, 0.83; 95% CI, 0.73 to 0.94; and HR, 0.69; 95% CI, 0.56 to 0.84, respectively).

Conclusions: Primary failure remains a major issue in the post-Fistula First era. Complications from AVF placement must be considered when planning AVF placement. Our data demonstrate that artery size is the main predictor of AVF patency.

Figure 1.

AVF outcomes at the end of follow-up (median, 379 days; interquartile range, 116 to 683 days). At the end of follow-up, 39.9% (117 of 293) of the AVFs were suitable for dialysis, but 26.6% (78 of 293) had primary failure, 13.0% (38 of 293) were not used because hemodialysis was not needed, 12.6% (37 of 293) had an indeterminate outcome, 5.1% (15 of 293) had secondary failure, 2.0% (6 of 293) were not used because the patients died before use, and 0.7% (2 of 293) were not used because the patients received a transplant before use.

Figure 2.

AVF outcomes for the patients who were on hemodialysis at some time during the study, had a known AVF outcome, and did not die or receive a transplant before AVF use (71.7%, 210 of 293). Primary failure occurred in 37.1% (78 of 210) of these AVFs. Approximately 55.7% (117 of 210) of the AVFs became suitable for dialysis at some point and did not fail, whereas 7.1% (15 of 210) of these AVFs had secondary failure.

Figure 3.

Kaplan–Meier survival curve for primary AVF patency. One patient known to have undergone intervention to preserve patency was excluded from these analyses because the dates of AVF intervention were unknown. The 3-, 6-, 12-, and 18-month event-free survival rates for primary patency were 67%, 50%, 41%, and 30%, respectively.

Figure 4.

Kaplan–Meier survival curve for secondary AVF patency. The 3-, 6-, 12-, and 18-month event-free survival rates for secondary patency were 92%, 86%, 77%, and 73%, respectively.