Comparison of the efficacy of upper arm transposed arteriovenous fistulae and upper arm prosthetic grafts.
OBJECTIVE
Direct comparison of transposed arteriovenous fistulas (tAVF) and arteriovenous grafts (AVG) has been hampered by inherent differences in patient characteristics between tAVF and AVG groups. In this study, using matching to control patient variables, we evaluated our outcomes with upper arm tAVF and upper arm prosthetic AVG.


METHODS
A retrospective review of all newly created upper arm tAVF and AVG was performed. One hundred ninety upper arm tAVF were group matched for age, gender, race, diabetes, and history of previous failed access with 168 AVG chosen from a pool of 476 concurrently performed AVG procedures. Complication, patency, and intervention rates were compared using multivariate analysis.


RESULTS
Mean follow up for our cohort was 29.1 months. Transposed fistulae consisted of 119 basilic vein and 71 cephalic vein transpositions, which were found to have similar demographic parameters, complication rates, and patency rates. There were no differences in 30 day mortality, 24 hour thrombosis, bleeding requiring exploration, or ischemic steal requiring intervention between the tAVF and AVG groups. More AVG developed infection requiring operative exploration than tAVF (7.9% vs 1.6%, respectively. P = .004). Primary patency for tAVF was higher than for AVG: 48% vs 14% at five years (P < .0001). Secondary patency rate for tAVF was also higher than for AVG: 57% vs 19% at five years (P < .0001). Nine percent of tAVF compared with 53% of AVG required one or more surgical and/or percutaneous revisions to maintain secondary patency (P < .0001). Multivariate analysis revealed that utilization of a tAVF was associated with a reduced risk of primary (Hazard Ratio [HR] 0.47, 95% Confidence Interval [CI] 0.35-0.64, P < .0001) and secondary failure (HR 0.59, 95% CI 0.42-0.81, P = .0001).


CONCLUSIONS
Transposed arteriovenous fistulas have significantly higher primary and secondary patency rates, require fewer revisions, and are less likely to develop a significant infection than AVG. This study supports the contention that as long as a patient is a candidate for a tAVF based on anatomic criteria, a tAVF should be considered before an AVG.
Divison of Vascular Surgery, Scripps Green Hospital, La Jolla, Calif, USA.
Karen
K
Woo
Gheorghe
G
Doros
Tina
T
Ng
Alik
A
Farber
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation*; D016121:Brachiocephalic Veins / Q000601:surgery*; D005260:Female; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000503:physiopathology / Q000601:surgery; D006801:Humans; D007511:Ischemia / Q000209:etiology / Q000503:physiopathology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D018579:Patient Selection; D019106:Postoperative Hemorrhage / Q000209:etiology / Q000503:physiopathology / Q000601:surgery; D016016:Proportional Hazards Models; D006435:Renal Dialysis; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D013530:Surgical Wound Infection / Q000209:etiology / Q000601:surgery; D013927:Thrombosis / Q000209:etiology / Q000503:physiopathology / Q000601:surgery; D013997:Time Factors; D016896:Treatment Outcome; D034941:Upper Extremity / Q000098:blood supply*; D014654:Vascular Patency