title: Arteriovenous grafts are associated with earlier catheter removal and fewer catheter days in the United States Renal Data System population.
abstract: OBJECTIVE
  Arteriovenous fistulas (AVFs) are associated with improved long-term outcomes but longer maturation times and higher primary failure rates compared with arteriovenous grafts (AVGs). The Fistula First Breakthrough Initiative has recently emphasized tunneled dialysis catheter (TDC) avoidance. We sought to characterize the relationship of AVFs and AVGs to the use of TDCs as well as secondary procedures.
  
  
  METHODS
  Using the United States Renal Data System (USRDS) database, we identified incident hemodialysis (HD) patients in 2005 that started HD with a TDC and survived at least 1 year. We then monitored them through 2008. Access creation, TDC removal, TDC placement, and secondary procedures were identified by Current Procedural Terminology codes (American Medical Association, Chicago, Ill). Multivariate logistic regression was used to identify risk factors for the primary end points.
  
  
  RESULTS
  In 2005, HD was initiated in 56,495 patients, 74% with a TDC. Of these, 6286 had an access procedure ≤3 months and 1 year of follow-up (AVF, 4634; AVG, 1652). Mean age was 67.7 years (AVF, 67.3; AVG, 68.7 years; P < .001), 53.3% were men (AVF, 58.1%; AVG, 40.5%; P < .001), and 33.8% were obese (AVF, 33.6%; AVG, 34.4%; P = not significant). AVG placement was associated with a higher TDC removal at 1 (7.9% vs 3.1%; P < .001), 3 (47.8% vs 17.8%; P < .001), and 6 (60.6% vs 47.2%; P < .001) months. There was no difference at 9 months (AVG, 64.9% vs AVF, 62.3%; P = .06). The median time to TDC removal was lower in the AVG group (70 days vs 155 days; P < .001). Multivariable model found AVFs were associated with decreased odds of TDC removal at 3 (odds ratio, 0.22; P < .001) and 6 months (odds ratio, 0.54; P < .001). AVGs required more secondary procedures than AVFs at all time points up to 1 year and specifically had increased thrombectomy procedures (39.8% vs 11.5%; P < .001).
  
  
  CONCLUSIONS
  In patients starting dialysis with a TDC, AVGs are associated with increased TDC removal and fewer catheter days compared with AVFs at up to 6 months. However, AVGs require more secondary procedures at all time points up to 1 year.
authors.affiliation: Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa. Electronic address: leakeae@upmc.edu.
authors.forename: Andrew E
authors.initials: AE
authors.lastname: Leake
authors.affiliation: Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Theodore H
authors.initials: TH
authors.lastname: Yuo
authors.affiliation: Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Timothy
authors.initials: T
authors.lastname: Wu
authors.affiliation: Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Larry
authors.initials: L
authors.lastname: Fish
authors.affiliation: Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Ellen D
authors.initials: ED
authors.lastname: Dillavou
authors.affiliation: Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Rabih A
authors.initials: RA
authors.lastname: Chaer
authors.affiliation: Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Steven A
authors.initials: SA
authors.lastname: Leers
authors.affiliation: Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
authors.forename: Michel S
authors.initials: MS
authors.lastname: Makaroun
mesh_terms: D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects; D002405:Catheterization, Central Venous / Q000009:adverse effects / Q000295:instrumentation*; D002408:Catheters, Indwelling; D062905:Central Venous Catheters; D016208:Databases, Factual; D020878:Device Removal; D005260:Female; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000503:physiopathology / Q000601:surgery; D006801:Humans; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D016017:Odds Ratio; D006435:Renal Dialysis; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D017131:Thrombectomy; D013927:Thrombosis / Q000209:etiology / Q000503:physiopathology / Q000601:surgery; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014654:Vascular Patency