Patency Outcomes of Arteriovenous Fistulas and Grafts for Hemodialysis Access: A Trade-Off between Nonmaturation and Long-Term Complications

Abstract

Background: Arteriovenous fistulas (AVFs) for hemodialysis (HD) are often associated with better outcomes than arteriovenous grafts (AVGs). We aimed to investigate vascular access (VA) outcomes and assessed if AVF nonmaturation outweighs long-term complications of AVGs.

Methods: In this multicenter, retrospective cohort study in The Netherlands, 1- and 3-year primary, primary assisted, secondary, and functional patency rates were calculated, and the incidence of adverse events and procedures was assessed. Functional patency of RCAVFs, upper arm AVFs, and AVGs was compared using Cox analyses.

Results: In total, 1041 patients who received their first VA were included, of whom 863 had VAs that successfully matured. These patients were analyzed with a median follow-up of 25 months. The 1-year functional patency rates were 67%±2.0% for RCAVFs, 83%±2.0% for upper arm AVFs, and 85%±3.5% for AVGs. Three-year functional patency rates were 62%±2.0% for RCAVFs, 74%±2.0% for upper arm AVFs, and 69%±5% for AVGs. AVGs required more procedures per year (3.3 per year) of functional patency when compared with upper arm AVFs (1.8 per year).

Conclusions: The functional patency of AVFs and AVGs is comparable, although AVGs required more interventions to maintain usability for HD. The choice of VA is a trade-off between short-term advantages, favoring AVGs, and long-term advantages, favoring AVFs. Which VA is most appropriate depends on the patient's prognosis and preferences.

Keywords: arteriovenous fistula; arteriovenous graft; dialysis; patency; vascular access.

Graphical abstract

Figure 1.

Visual example of patency measures. VA, vascular access.

Figure 2.

Flowchart of inclusion and exclusion from analysis. AVF, arteriovenous fistula; AVG, arteriovenous graft; RCAVF, radiocephalic arteriovenous fistula.

Figure 3.

Postcannulation primary patency of RCAVF that matured with and without interventional procedures, excluding RCAVFs that never matured.

Figure 4.

Primary, primary assisted, secondary, and functional patency for RCAVFs, upper arm AVFs, and AVGs. Patients are censored for death and transplantation. (A–D) Clinical outcomes of all VAs, excluding VAs that did not mature (n=863). (E–H) Clinical outcomes of all VAs, including nonmatured VAs (n=1041).

Figure 5.

Postintervention primary patency of RCAVF after subsequent procedures. Postintervention patency starts at the index procedure and ends at the next procedure, occlusion, or abandonment of the VA, and patients are censored for death and transplantation.