Cumulative patency of contemporary fistulas versus grafts (2000-2010).
OBJECTIVE
Comparisons of fistulas and grafts often overlook the high primary failure rate of fistulas. This study compared cumulative patency (time from access creation to permanent failure) of fistulas and grafts.


METHODS
Vascular accesses of 1140 hemodialysis patients from two centers (Toronto and London, Ontario, Canada, 2000-2010) were analyzed. Cumulative patency was compared between groups using Kaplan-Meier survival curves and log-rank tests. Hazard ratios (HRs) for fistula failure relative to grafts and 95% confidence intervals (95% CIs) are reported.


RESULTS
There were 1012 (88.8%) fistulas and 128 (11.2%) grafts. The primary failure rate was two times greater for fistulas than for grafts: 40% versus 19% (P<0.001). Cumulative patency did not differ between fistulas and grafts for the patients' first access (median, 7.4 versus 15.0 months, respectively [HR, 0.99; 95% CI, 0.79-1.23; P=0.85]) or for 600 with a subsequent access (7.0 versus 9.0 months [HR, 0.93; 95% CI, 0.77-1.13; P=0.39]). However, when primary failures were excluded, cumulative patency became significantly longer for fistulas than for grafts for both first and subsequent accesses (61.9 versus 23.8 months [HR, 0.56; 95% CI, 0.43-0.74; P<0.001] and 42.8 versus 15.9 months [HR, 0.56; 95% CI, 0.44-0.72; P<0.001]). Results were similar for forearm and upper-arm accesses. Compared with functioning fistulas, grafts necessitated twice as many angioplasties (1.4 versus 3.2/1000 days, respectively; P<0.001) and significantly more thrombolysis interventions (0.06 versus 0.98/1000 days; P<0.001) to maintain patency once matured and successfully used for dialysis.


CONCLUSIONS
Cumulative patency did not differ between fistulas and grafts; however, grafts necessitated more interventions to maintain functional patency.
Division of Nephrology, Department of Medicine, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada. charmaine.lok@uhn.ca
Charmaine E
CE
Lok
Jessica M
JM
Sontrop
George
G
Tomlinson
Dheeraj
D
Rajan
Mark
M
Cattral
George
G
Oreopoulos
Jeremy
J
Harris
Louise
L
Moist
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017130:Angioplasty; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects / Q000379:methods*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects; D005260:Female; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009864:Ontario; D006435:Renal Dialysis; D012189:Retrospective Studies; D012307:Risk Factors; D015912:Thrombolytic Therapy; D013997:Time Factors; D016896:Treatment Outcome; D034941:Upper Extremity / Q000098:blood supply*; D014654:Vascular Patency; D055815:Young Adult