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Comparison of Lower Extremity Dialysis Access and Hemodialysis Reliable Outflow grafts using the Vascular Quality Initiative Hemodialysis Access Registry
Katherine Owsiany, Olamide Alabi, Manuel Garcia-Toca, Yazan Duwayri
Emory University, Atlanta, GA

INTRODUCTION: Hemodialysis access becomes even more challenging when standard upper extremity access options are exhausted. Arteriovenous fistulae and grafts in the lower extremity (LE-AVF and LE-AVG) as well as Hemodialysis Reliable Outflow (HeRO) grafts are commonly used for patients with limited options for hemodialysis access. There is limited data on the safety and efficacy of “last resort” hemodialysis access types.
METHODS: We performed a secondary analysis of Vascular Quality Initiative data to examine outcomes after lower extremity access and HeRO access. We compared standard demographics and examined access functional patency (from date first used to date last used) and mortality using Kaplan-Meier analysis at 6 months, 1 year, and 2 years after access creation. We compared all lower extremity access to HeRO grafts and performed a subgroup analysis of LE-AVF to HeRO grafts.
RESULTS: Our study population was comprised of 233 HeRO grafts, 190 LE-AVF, and 1109 LE-AVG. Compared to those who underwent any lower extremity access procedure, recipients of HeRO grafts were significantly older (58(+/-0.76) years vs 56.7(+/-0.55) years, p<0.01) and patients in both groups had an average of greater than 2 prior access attempts (2.11 vs 2.35, p=0.69). Compared to all lower extremity access, HeRO grafts had significantly higher functional patency at 6 months (98% vs 81%, p=0.0015) but there was no difference noted at 1 year (37% vs 45%, p=0.25). Compared to LE-AVF, HeRO grafts had significantly higher functional patency at 6 months (98% vs 73.3%, p<0.001) but, again, there was no difference noted at 1 year (37% vs 30%, p=0.12). At 2 years of follow up, there were no HeRO grafts that maintained functional patency compared to 12% of lower extremity access procedures that were patent at this timeframe (p=0.045). HeRO grafts required significantly more reinterventions during their duration of functional patency (1.67 vs 2.7, p=0.004). Overall mortality was not significantly different between LE-AVF, LE-AVG, and HeRO grafts (5% vs 17% vs 15% p=0.44).
CONCLUSIONS: HeRO grafts show higher functional patency in the first 6 months after access creation but decline steeply in patency thereafter compared to lower extremity dialysis access. Further studies should determine new methods (such as using the 2 strategies in tandem) and/or alternative conduit types that may help prolong the longevity of “last resort” access.

Demographic Characteristics of LE access and HeRO procedures
LE-AVFLE-AVGHeROp value
Age (SD)50.4(2.3)56.7(0.5)58 (0.8)0.004
Sex (M)62%47.2%47.2%0.124
Race (White)47%36.6%36.5%0.366
Race (AA)36%54.9%56.9%
Race (other)16.6%9.3%6.5%
Ethnicity (Hispanic)12.7%6.1%8.3%0.197
Ethnicity (non-Hispanic)87.2%93.8%91.6%
Previous HD access (SD)2.0 (0.1)2.226 (0.01)2.35 (0.07)0.692

Mortality and Outcomes of LE access and HeRO procedures
LE-AVFLE-AVGHeROp value
Infection23.7%9.7%0%0.08
Thrombosis39%33.8%46.6%0.148
Steal syndrome0%0.01%0%0.8
# Reinterventions1.67 (0.1)1.67 (0.01)2.70 (0.09)0.004
Mortality at 6 months0%3%3%0.56
Mortality at 12 months2%7%9%0.19
Mortality at 24 months5%17%15%0.44


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