title: Multiple preoperative and intraoperative factors predict early fistula thrombosis in the Hemodialysis Fistula Maturation Study.
abstract: OBJECTIVE
  Early thrombosis (ET) contributes to autogenous arteriovenous fistula (AVF) failure. We studied patients undergoing AVF placement in the Hemodialysis Fistula Maturation Study, a prospective, observational cohort study, using a nested case-control analysis to identify preoperative and intraoperative predictors of ET.
  
  
  METHODS
  ET cases were compared with controls, who were matched for gender, age, diabetes, dialysis status, and surgeon fistula volume. ET was defined as thrombosis diagnosed by physical examination or ultrasound within 18 days of AVF creation. Conditional logistic regression models were fit to identify risk factors for ET.
  
  
  RESULTS
  Thirty-two ET cases (5.3%) occurred among 602 study participants; 198 controls were matched. ET was associated with female gender (odds ratio [OR], 2.75; 95% confidence interval [CI], 1.19-6.38; P = .018), fistula location (forearm vs upper arm; OR, 2.76; 95% CI, 1.05-7.23; P = .039), feeding artery (radial vs brachial; OR, 2.64; 95% CI, 1.03-6.77; P = .043) and arterial diameter (OR, 1.52; 95% CI, 1.02-2.26; P = .039, per mm smaller). The draining vein diameter was nonlinearly associated with ET, with highest risk in 2- to 3-mm veins. Surprisingly, ET risk was lower in diabetics (OR, 0.19; 95% CI, 0.07-0.47; P = .0004), lower with less nitroglycerin-mediated brachial artery dilation (OR, 0.42; 95% CI, 0.20-1.92; P = .029 for each 10% lower) and higher with lower carotid-femoral pulse wave velocity (OR, 1.49; 95% CI, 1.02-2.20; P = .041, for each m/s lower). Intraoperative protamine use was associated with a higher ET risk (OR, 3.26; 95% CI, 1.28-∞; P = .038). Surgeon's intraoperative perceptions were associated with ET: surgeons' greater concern about maturation success (likely, marginal, unlikely) was associated with higher thrombosis risk (OR, 8.09; 95% CI, 4.03-∞; P < .0001, per category change), as were absence vs presence of intraoperative thrill (OR, 21.0; 95% CI, 5.07-∞; P = .0001) and surgeons' reported frustration during surgery (OR, 6.85; 95% CI, 2.70-∞; P = .0004). Decreased extent of intraoperative thrill (proximal, mid or distal third of the forearm or upper arm, based on AVF placement) was also associated with ET (OR, 2.91; 95% CI, 1.31-∞; P = .007, per diminished level). Oral antithrombotic medication use was not significantly associated with ET.
  
  
  CONCLUSIONS
  ET was found to be associated with female gender, forearm AVF, smaller arterial size, draining vein diameter of 2 to 3 mm, and protamine use. Paradoxically, diabetes and stiff, noncompliant feeding arteries were associated with a lower frequency of ET. Absent or attenuated intraoperative thrill, and both surgeon frustration and concern about successful maturation during surgery, were correlated strongly with ET.
authors.affiliation: Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, Mass. Electronic address: alik.farber@bmc.org.
authors.forename: Alik
authors.initials: A
authors.lastname: Farber
authors.affiliation: Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Department of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.
authors.forename: Peter B
authors.initials: PB
authors.lastname: Imrey
authors.affiliation: Division of Vascular Surgery, University of Florida College of Medicine, Gainesville, Fla.
authors.forename: Thomas S
authors.initials: TS
authors.lastname: Huber
authors.affiliation: VA Boston Healthcare System, Boston, Mass; Division of Nephrology, VA New York Harbor Healthcare System, and Division of Nephrology, New York University School of Medicine, New York, NY.
authors.forename: James M
authors.initials: JM
authors.lastname: Kaufman
authors.affiliation: Division of Vascular Surgery, University of Utah, Salt Lake City, Utah.
authors.forename: Larry W
authors.initials: LW
authors.lastname: Kraiss
authors.affiliation: Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Brett
authors.initials: B
authors.lastname: Larive
authors.affiliation: Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio; Department of Biostatistics, MD Anderson Cancer Center, Houston, Tex.
authors.forename: Liang
authors.initials: L
authors.lastname: Li
authors.affiliation: Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology, and Renal-Electrolyte & Hypertension Division, University of Pennsylvania Perlman School of Medicine, Philadelphia, Pa.
authors.forename: Harold I
authors.initials: HI
authors.lastname: Feldman
mesh_terms: D000328:Adult; D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects* / Q000379:methods / Q000523:psychology; D001291:Attitude of Health Personnel; D016022:Case-Control Studies; D015897:Comorbidity; D005260:Female; D005542:Forearm / Q000098:blood supply*; D006083:Graft Occlusion, Vascular / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology; D006494:Heparin Antagonists / Q000009:adverse effects; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010808:Physical Examination; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011479:Protamines / Q000009:adverse effects; D065840:Protective Factors; D006435:Renal Dialysis; D012307:Risk Factors; D012737:Sex Factors; D066231:Surgeons / Q000523:psychology; D013927:Thrombosis / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D014481:United States
chemical_list: D006494:Heparin Antagonists; D011479:Protamines