Temporal Trends in Hemodialysis Access Creation in the Fistula First Era: Are Rates of Forearm Arteriovenous Fistulas Increasing?
James J Fitzgibbon1, Patrick Heindel1, Abena Appah-Sampong1, Dirk M Hentschel1, Muhammad Mamdani2, Charles K Ozaki1, Mohamad A Hussain1
1Brigham and Women's Hospital, Boston, MA;2Unity Health, Toronto, ON, Canada
INTRODUCTION: Although forearm arteriovenous fistulas (AVFs) are the preferred initial vascular access for hemodialysis based on national guidelines, there are no population-level studies evaluating trends in creation of forearm versus upper arm AVFs and arteriovenous grafts (AVGs). The purpose of this study was to report temporal trends in first-time hemodialysis access placement type, and to understand the impact of national initiatives on rates of AVF placement. METHODS: We conducted a retrospective cross-sectional study from 2012 to 2022 utilizing the Vascular Quality Initiative (VQI) database. All patients older than 18 with creation of first-time upper extremity surgical hemodialysis access were included. Anatomical location of the AVF or AVG (forearm versus upper arm) was defined based on inflow artery, outflow vein, and cannulation zone. Primary analysis examined temporal trends in rates of forearm versus upper arm AVF and AVG using time series analyses (modified Mann-Kendall test). Secondary analyses examined rates of access configuration stratified by age, sex, race, and dialysis status. In addition, we conducted an interrupted time series analysis to study the effect of the Fistula First Catheter Last (FFCL) initiative (implemented in 2015) on rates of AVF placement as it occurred during our study period.
RESULTS: A total of 52,170 patients were included. Access configuration consisted of 57.9% upper arm AVFs, 25.2% forearm AVFs, 15.4% upper arm AVGs, and 1.5% forearm AVGs. From 2012 to 2022, there was no significant change in overall rates of forearm AVFs, upper arm AVFs, or upper arm AVGs, whereas forearm AVGs declined (1.8 to 0.7 per 100, p=0.018, Figure 1). In subgroup analyses, we observed a decrease in forearm AVFs among men (33.1 to 28.7 per 100, p=0.042), while female (17.2 to 23.1 per 100, p=.029), black (15.6 to 24.5 per 100, p=0.001), and elderly (age≥80) patients (18.7 to 32.5 per 100, p< 0.001) had a significant increase in upper arm AVGs. The FFCL initiative in 2015 had no significant effect on the rate of AVF placement (83.2 to 83.7 per 100, p=0.37, Figure 2).
CONCLUSIONS:Despite national initiatives to promote autogenous vascular access, the rates of first-time AVFs have not increased, with forearm AVFs only representing one-quarter of all permanent surgical accesses. Furthermore, elderly, black, and female patients saw an increase in upper arm AVGs. Efforts to elucidate factors associated with forearm AVF placement as well as potential regional and center-level variation are warranted.
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