Primary and Assisted Patency of Vascular Access in End Stage Renal Disease Patients at One Year: An Audit of All Vascular Access Procedures

      Introduction: Vascular access is still considered the ‘Achilles heel’ of haemodialysis. It is important to analyse the current practice outcomes, including patency rates and timing of formation of access in the predialysis population, as these are important parameters for the management of the vascular access pathway in patients with end stage renal disease (ESRD).
      Methods: This study was conducted at a tertiary centre serving a dialysis population of over 600 patients. It was a retrospective, observational study of vascular access procedures performed between January 2019 and December 2020. Patient data were collected from electronic patient records, the operation theatre database, and clinical case records. All patients were followed up for a period of 12 months. The primary failure rates were defined as failure immediately or within three months of the access creation. Primary patency derived from access, which remained patent without any intervention, whereas primary assisted patency was derived for those needing interventions to maintain the patency. Secondary patency involved those where intervention was required following thrombosis to re-establish access. Statistical analysis was done using SPSS version 23.0 applying Pearson’s chi square test to measure the significance of outcomes.
      Results: A total of 229 vascular access procedures were performed in 203 patients. In total, 176 (76.8%) were vascular access formations, while the remaining 53 (23.1%) were procedures to treat complications of established vascular access. Mean ± SD age was 63.8 ± 14.3 years (63.1% men and 36.9% women); 43.7% had diabetes. Of the 176 procedures, 162 were autogenous arteriovenous fistula formation, while 14 were non-autogenous arteriovenous graft procedures. The mean age of those having autogenous fistula was 64.5 ± 13.9 years and 65.4% were men. While patients undergoing arteriovenous graft had a mean age of 55.4 ± 15.6 years and 35.7% were men. Patients undergoing arteriovenous graft surgeries were significantly younger (p < .05) with a female predominance (p < .05), compared to those having autogenous fistulas. Ninety-two (52.3%) procedures were performed in the predialysis population; their mean estimated glomerular filtration rate (eGFR) at the time of operation was 11.15 mL/minute/1.73 m2. In the predialysis group, 24 (13.6%) had a functioning access at 12 months but did not require dialysis. The overall six month primary, primary assisted, and secondary patency rates were 73.3%, 79.4%. and 82.4%, respectively, whereas the 12 month primary, primary assisted, and secondary patency rates were 63.7%, 70.3%, and 73.4%, respectively. These data were censored for deaths, transplants, those lost to follow up, and transfers. The primary failure rate was 13.6% (n = 24) among all procedures. There were 33 (18.7%) radiological interventions with or without thrombectomy and 41 (23.3%) were secondary surgical interventions. Twelve (16.8%) patients underwent renal transplantation during the follow up period, while 18 (10.2%) were deceased. The one year patency rates for brachiocephalic fistula was 74.4% versus 73% for radiocephalic fistula, while two staged basilic vein transpositions had a one year secondary patency rate of 90%. Autogenous fistulas provided significantly superior results compared with non-autogenous graft surgeries in terms of secondary patency rate, 73.8% versus 69.2% (p < .05). Autogenous fistulas also had significantly fewer interventions compared with those for arteriovenous grafts (35.9% vs. 46.1%; p < .05). Nineteen per cent (n = 33) of the study population were still dialysing through a central venous line catheter by the end of the follow up period.
      Conclusion: Autogenous arteriovenous fistulas had better patency and had fewer interventions than arteriovenous grafts. Patients who had graft formations were younger, with a female predominance. Basilic vein transpositions had the best secondary patency rates at one year. Wrist and elbow fistula patency was comparable, possibly owing to appropriate case selection. Timing of access creation in predialysis patients is crucial. We feel that our cohort were listed appropriately.


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