Slowly moving the needle away from Fistula First
Ghandour H, Cataneo JL, Asha A, et al. Slowly moving the needle away from Fistula First [published online ahead of print, 2023 Nov 10]. J Vasc Surg. 2023;S0741-5214(23)02206-1. doi:10.1016/j.jvs.2023.11.007
Objective:In 2019, the management of end-stage kidney disease (ESKD) shifted away from "Fistula First" (FF) to "ESKD Life-Plan: Patient Life-Plan First then Access Needs." Indeed, some patients exhibit such excessive comorbidity that even relatively minor vascular surgery may be complicated. The purpose of this study was to retrospectively assess complications and mortality (and delineate operative futility) in patients undergoing arteriovenous fistula (AVF) creation in the FF era.
Methods:Consecutive AVFs created in a single institution before 2021 were retrospectively reviewed. Operative futility was defined as never-accessed fistula, no initiation of dialysis, failure of access maturation (despite secondary intervention), hemodialysis access induced distal ischemia requiring ligation, early loss of secondary patency and/or patient mortality within the first 6 post-operative months.
Results:A total of 401 AVFs were created including radial-cephalic (44%), brachial-cephalic (41%) and brachial-basilic (15%) constructions. Patients exhibited a mean age of 69±15 years; 63% were male and most (74%) were already being hemodialyzed at the time of fistula creation. 45 patients (11%) suffered a cardiac event and 5 patients died (1%) within 90 days of their access surgery. Perioperative cardiac events were significantly more common after age 80 (19% vs. 8%; p=0.004); age >80 years was an independent predictor of major 90-day complications (OR=1.88 [1.04-3.39]; p=0.036) and the sole independent predictor of major morbidity defined as cardiopulmonary complications, stroke, or death within the first year (OR=2.01 [1.24-3.25]; p=0.004). Operative futility was encountered in 52% of the cohort (n=208 patients): 40% (n=160) of primary AVFs failed to mature despite assistance, 19% (n=77) had lost secondary patency by 6 months, 13% of patients (n=53) were never started on dialysis after access creation, 4% (n=16) were dead by 6 months, 2% of AVFs (n=10) matured but were never accessed and 2% (n=9) required ligation for hemodialysis access induced distal ischemia. Not surprisingly, the sole independent protector against operative futility was that catheter-based dialysis had been established prior to AVF creation (OR=0.36 [0.22-0.59]; p<0.01).
Conclusions:Approximately 50% of primary AVF operations performed in the aggressive FF era were deemed futile. Octogenarians were particularly prone to futility and complications during this era. A paradigm shift, from FF to an "ESKD Life-Plan" will, hopefully, more thoughtfully match vascular access strategies to individual patient needs.