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Arteriovenous Graft versus Arteriovenous Fistula as Initial Hemodialysis Access in the Super Elderly: A Vascular Quality Initiative Analysis
Elizabeth H Weissler, Leila H Mureebe, Lindsey A Olivere, Chandler H Long, Kevin W Southerland
Duke University, Durham, NC

Introduction: The rate of patients over the age of 75 on hemodialysis (HD) continues to rise at a rate of 8-16% a year. Guidelines dictate a “fistula first, catheter last” approach. Arteriovenous fistulas (AVF) are certainly a more durable access option than arteriovenous grafts (AVG); however, their utility in elderly patients remains unknown. There is some evidence that arteriovenous fistulae (AVF) among elderly patients have lower patency and do not reliably lead to use for HD. Prior research on elderly AVF creation has relied on single center retrospective reviews, non-surgical datasets, or has defined elderly as older than 65-75 years old. We aimed to assess the effectiveness of a fistula first approach for dialysis access in patients over the age of 80.
Methods: We queried the Vascular Quality Initiative database from 2011 to 2020 for all patients undergoing HD access. Patients who died were excluded from analysis of patency and HD access use. Patient, procedural characteristics, and outcomes were compared using Pearson Χ2 tests for categorical variables and Wilcoxon rank-sum tests for continuous variables.
Results: 5,846 (69.7%) patients over the age of 80 underwent AVF creation and 2,175 (26.2%) underwent AVG. The 1 year mortality was 36.9%. During the first 6 months following access creation, 38.7% of elderly AVG patients (eAVG) used their AVG while only 15.35% of elderly AVF patients (eAVF) did (p<0.0001). Beyond 6 months, 69.6% of eAVG used their accesses for HD versus 57.7% in eAVF (p<0.001). A higher number of eAVF patients never used their fistulasfor HD at all (63.5% vs 41.8%). eAVG more frequently underwent percutaneous re-interventions (45.5% vs 33.0%, p<0.001). eAVF more frequently underwent surgical re-interventions (18.7% in AVF vs 13.6%, p=0.007).
Conclusions:
Hemodialysis use in octo- and nonagenarians continues to rise. The optimal hemodialysis modality for these patients remains unknown. In this patient population, initial AVG placement results in improved access utility and decreased surgical re-intervention compared to AVF placement. Given the myriad of medical comorbidities, frailty, and overall limited life expectancy of elderly dialysis patients, a morbidity-limiting approach that emphasizes reduction in catheter time and re-interventions should be prioritized over a fistula first strategy aimed at achieving durable access.


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