7/7/2015. Disclosures. ARS question #1. Michael Allon, M.D. University of Alabama at Birmingham, USA. CorMedix consultant Gore - consultant

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1 7/7/25 Michael Allon, M.D. University of Alabama at Birmingham, USA Disclosures CorMedix consultant Gore - consultant Forearm AVG before upper arm AVF: Pros and Cons Tradeoffs of upper arm AVF vs AVG Retrospectively identified patients with forearm AVF that failed to mature, who subsequently had an AVG or upper AVF placed. Most were already on HD, using catheters. Compared multiple access outcomes between the two patient groups. ARS question # Primary failure (new access that is never usable for dialysis) is more common with: A. AVF B. AVG Primary access failures more common with AVF than AVG Primary failure is higher for AVF than AVG (side-by-side contemporary comparisons) Primary failure (%) Reference AVF AVG AVF AVG Maya, 29 N of patients % 5% Lok, % 9% Maya, CJASN 4: 86-92, 29 Lok, CJASN 8: 8-88, 23 Prim failure p<.

2 7/7/25 AVF require more interventions to achieve access maturation Number of interventions How often is an intervention required before access can be used for HD? Falk reported on 54 AVF o 42% required > interv to achieve maturation Lee reported on 73 AVF o 44% required > interv to achieve maturation Harms reported on 289 AVF and 3 AVG o 5% of AVF required > interv before use o 8% of AVG required > interv before use Falk, JVIR 7: 87-83, 26 Lee, CJASN 6: , 2 Harms, 25 NKF spring clinical meeting poster Hurdles to achieving usable AVF in catheter-dependent patients: Fresenius 28,44 pts started HD in 28 77% started with a catheter. Of pts starting with a catheter and maturing AVF, only 2% were catheterfree at 9 days. Of pts starting with a catheter and maturing AVG, 54% were catheter-free at 9 days. Lacson et al, 29 ASN free communication ARS question #2 Time from access creation to first successful cannulation is: A. Longer for AVF B. Longer for AVG Time to first AVF cannulation in U.S. DOPPS: 2% cannulated within month. Time to first AVG cannulation in the U.S. DOPPS: 78% cannulated within month. Months after AVF surgery Saran, NDT 9: , 24 Weeks after AVG surgery Saran, NDT 9: , 24 2

3 7/7/25 AVF entail longer catheter dependence before their use. Risk of bacteremia increases with duration of catheter-dependence 4 3 Catheter dependence (days) First CRB: 3 months: 35% 6 months: 54% year: 79% N=472 Shingarev, JVIR 24: , 23 Patients with AVF have more catheter infections before access use.4.33 Outcomes of AVF vs AVG BEFORE MATURATION AVF AVG p-value N patients 59 5 CRB before access use Primary failures 44% 2%.6 Interv. before maturation Catheter dependence 3 34 <. (days) #CRB before maturation Median access survival Median access survival greater for AVF(excluding prim failures) ARS question #3 If you include (intent-totreat analysis) access survival is: A. Longer for AVF B. Longer for AVG 3

4 7/7/25 Cumulative survival of AVF vs AVG Cumulative survival of AVF vs AVG Excluding 2 AVF 28 AVG Excluding Maya, CJASN 4: 86-92, 29 Including Lok, CJASN 8:8-88, 23 Including Cumulative survival of AVF vs AVG Secondary survival of AVF and AVG are similar (when are included) Including 998 AVF 72 AVG Cumulative survival at year (Graft/fistula) Schild, J Vasc Acc 9:23-235, 28. Palder Coburn Rocco Miller Hodges Gibson Oliver Allon, CJASN 2: 786-8, 27 Allon 2 Dixon 22 ARS question #4 Which type of access requires more frequent interventions to maintain patency for dialysis? A. AVF B. AVG Access interventions per year AVF require fewer interventions than AVG to maintain patency for HD

5 7/7/25 AVG require more interventions than AVF to maintain patency for HD Revision rate per access-year (Graft/fistula) Outcomes of AVF vs AVG AFTER MATURATION AVF AVG p-value 8 7 N patients Winsett 985 Rocco 996 Miller 997 Hodges 997 Gibson 2 Oliver 2 Allon 2 McCarley 2 Dixon 22 Median survival in days (excluding prim failures) Interv. per year after access maturation <. Allon, CJASN 2: 786-8, 27 What is the impact of interventions prior to maturation on access survival and frequency of interventions after use? AVF that require interventions to achieve maturation have shorter survival. Median surv 2 years: Same as AVG! Excluding Lee, CJASN 6: , 2 AVF that require interventions to achieve maturation have shorter survival than AVG without intervention! Harms, NKF spring clinical meeting poster _ AVF that require intervention to achieve maturation require more interventions after maturation. Lee et al o Annual frequency of AVF intervention after maturation interv before maturation:.76/yr interv before maturation:.37/yr >2 interv before maturation: 3.5/yr Harms et al o Annual frequency of AVF intervention after maturation interv before maturation:.46/yr > interv before maturation:.84/yr Lee, CJASN 6: , 2 Harms, 25 NKF spring clinical meeting poster 5

6 7/7/25 Forearm AVG dilates prox. vein, suitable for future upper arm AVF creation Forearm AVG before upper arm AVF: Pros AVG mature faster (shorter CVCdependence) AVG have a lower primary failure rate. AVG require fewer interventions before use. Don t lose precious real estate. AVG dilate proximal veins makes it easier to create an upper arm AVF. Forearm AVG before upper arm AVF: Con AVG have shorter survival than AVF. AVG require more interventions to maintain patency for HD. This goes against the KDOQI vascular access guidelines. KDOQI vascular access guidelines: Preferred order of access type If you ignore AVF that fail to mature! First choice: forearm (radiocephalic) AVF Second choice: brachiocephalic AVF 6

7 7/7/25 Third choice: transposed brachiobasilic fistula Fourth choice: AVG Given these guidelines, how can we expect forearm AVG before upper arm AVF??? Forearm AVG are disappearing! Based on preop mapping, only ~5% of patients are suitable for a forearm AVF. Years HD population # forearm AVG placed per year ~ ~5 2 The number of new forearm AVG placed annually at UAB has decreased by 75% despite a >4% increase in the HD population Miller, AJKD 36: 68-74, 2 Shingarev, AJKD 58: 243-7, 2 Should the other 5% receive a forearm AVG before proceeding to an upper arm AVF? What are the implications of changing the policy to recommend forearm AVG before upper arm AVF? The first access would be a forearm AVF in ~5% and a forearm AVG in 5% of patients. Among the ~5% of patients whose forearm AVF fails to mature, the second access would be a forearm AVG. Such a policy would greatly reduce the prevalence of AVF among HD patients, but also reduce CVC use. It s time to overhaul the Fistula First guidelines! 7