Revisions to Promote Maturation and Short Term Death After Arteriovenous Fistula Creation

Arteriovenous fistula (AVF) for hemodialysis access is traditionally considered superior to grafts due to infection resistance and purported improved patency. However, challenges to AVF maturation and limited patient survival may reduce AVF benefit. The objective of this study is to identify factors associated with risk of AVF requiring revision before maturation and/or death within 2 years of creation. We performed a retrospective review of 243 AVF created between June 2017 and November 2020 at a single institution. Maturation was defined as the date the surgeon deemed the AVF ready or the patient successfully used the AVF for dialysis. The modified Risk Analysis Index was used to calculate frailty. The primary outcome was a composite of endovascular/surgical revision to promote maturation and/or death within 2 years of AVF creation (REVDEAD2). Survival at 2 years post-AVF was 67% (Fig 1), and 54 (22%) underwent AVF revision, with 31 (58%) of those who went on to mature their AVF. Eight patients underwent AVF revision and died within 2 years. Of the 243 AVFs, 89 (36%) met the primary outcome of REVDEAD2 vs 154 (63%) who did not. There was no difference between the groups in age, sex, race, Hispanic ethnicity, obesity, coronary artery disease, congestive heart failure, diabetes mellitus, dialysis status, hypertension, peripheral artery disease, or dysrhythmia. There was no difference between the groups in forearm vs upper arm AVF or vein diameter. More patients in REVDEAD2 were frail or very frail (43% vs 30%). Of the AVF that matured, maturation required longer time in REVDEAD2 (111 vs 79 days; P = .003). Adjusted for vein diameter and forearm vs upper arm, frailty increased the odds of REVDEAD2 by 2.0 (95% confidence interval, 1.2-3.6). Frail patients who underwent AVF were significantly more likely to need revision procedures to promote AVF maturation and/or die within 2 years of AVF creation. Patients who are frail may not receive all the benefits of fistula over graft and may be appropriate candidates for preferentially creating AV grafts.