Radiocephalic and brachiocephalic arteriovenous fistula outcomes in the elderly.
BACKGROUND
A recent meta-analysis has suggested that patients aged >65 have worse outcomes with radiocephalic arteriovenous fistulas (RCAVFs) compared with brachiocephalic arteriovenous fistulas (BCAVFs). We hypothesized that outcomes in patients aged > or = 80--a rapidly expanding cohort within this elderly group--might be skewing the results, and that age >65 may not be a contraindication to RCAVF formation. This study examined the effect of age group (<65, 65 to 79, >or =80) on functional outcomes (use; primary and secondary functional patency) in RCVAFs and BCAVFs.


METHODS
We identified the outcomes of all patients undergoing a first surgical access procedure for a RCAVF or BCVAF between January 1, 2000, and December 31, 2005. We examined the effect of age and other factors including sex, diabetes mellitus, hypertension, late referral (<3 months before dialysis), dialysis before surgical access, preoperative duplex ultrasound imaging, and ethnicity on non-AVF use and primary and secondary functional AVF patency. Logistic regression and Cox proportional hazards regression models were used.


RESULTS
From a total of 658 patients, 361 had a RCAVF, and 297 had a BCAVF. Their median age was 68.5 years (interquartile range [IQR], 54.4 to 76.5 years), and 288 (43.8%) were aged <65 years, 274 (41.6%) were 65 to 79, and 96 (14.6%) were > or =80. Age did not influence the site of the first surgical access (P = .874). Only 85.7% of patients actually progressed to hemodialysis, and the RCAVF or BCAVF in 45.7% of those was never used for dialysis. Female sex (hazard ratio [HR], 2.24; 95% confidence interval [CI] 1.387 to 3.643; P = .001) was the only factor associated with an increase risk of RCAVF nonuse, whereas diabetes (HR, 2.095; 95% CI, 1.261 to 3.482; P = .004) was the only factor associated with an increase risk of BCAVF nonuse. The respective primary patency rates at 1 and 2 years for RCAVFs were 46.0% and 27.1% for patients <65, 47.0% and 36.0% for those 65 to 79, and 45.7% and 38.1% for those >or =80. Only female sex (HR, 1.679; 95% CI, 1.261 to 2.236; P = .001) and prior hemodialysis (HR, 1.363; 95% CI, 1.0.29 to 1.804; P = .031) were associated with loss of patency of RCAVFs. The primary functional patency rates for BCAVFs at 1 and 2 years were 39.3% and 31.0% for those <65 years; 53.30% and 37.5% for those 65 to 79, and 46.3% and 42.6% for those >or =80. No factors analyzed were associated with loss of primary functional patency of BCAVFs.


CONCLUSIONS
Age did not affect usability, primary or secondary patency of either RCAVFs or BCAVFs. Although patient selection is important, even patients > or =80 years who are considered suitable for surgical placement of access should not be denied a RCAVF solely because of age.
Weale
Andy R
AR
Department of Vascular and Transplant Surgery, Southmead Hospital, North Bristol NHS Trust, Westbury on Trym, Bristol, Avon, United Kingdom. andy@weale.org.uk
Bevis
Paul
P
Neary
William D
WD
Boyes
Simon
S
Morgan
Justin D
JD
Lear
Paul A
PA
Mitchell
David C
DC
D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical / Q000009:adverse effects; D001132:Arm / Q000098:blood supply*; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects*; D001916:Brachial Artery / Q000601:surgery*; D016121:Brachiocephalic Veins / Q000601:surgery*; D004739:England; D005260:Female; D005500:Follow-Up Studies; D006299:Health Services for the Aged; D006801:Humans; D016015:Logistic Models; D008297:Male; D018579:Patient Selection; D016016:Proportional Hazards Models; D017534:Radial Artery / Q000601:surgery*; D006435:Renal Dialysis; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012737:Sex Factors; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency