title: A comparison of patency and interventions in thigh versus Hemodialysis Reliable Outflow grafts for chronic hemodialysis vascular access.
abstract: OBJECTIVE
  With improvements in medical management and survival of patients with end-stage renal disease, maintaining durable vascular access is increasingly challenging. This study compared primary, assisted primary, and secondary patency, and procedure-specific complications, and evaluated whether the number of interventions to maintain or restore patency differed between prosthetic femoral-femoral looped inguinal access (thigh) grafts and Hemodialysis Reliable Outflow (HeRO; Hemosphere Inc, Minneapolis, Minn) grafts.
  
  
  METHODS
  A single-center, retrospective, intention-to-treat analysis was conducted of consecutive thigh and HeRO grafts placed between May 2004 and June 2015. Medical history, interventions to maintain or restore patency, and complications were abstracted from the electronic medical record. Data were analyzed using parametric and nonparametric statistical tests, Kaplan-Meier survival methods, and multivariable proportional hazards regression and logistic regression.
  
  
  RESULTS
  Seventy-six (43 thigh, 33 HeRO) grafts were placed in 61 patients (54% male; age 53 [standard deviation, 13] years). Median follow-up time in the intention-to-treat analysis was 21.2 months (min, 0.0; max, 85.3 months) for thigh grafts and 6.7 months (min, 0.0; max, 56.3 months) for HeRO grafts (P = .02). The groups were comparable for sex, age, coronary artery disease, diabetes mellitus, peripheral vascular disease, and smoking history (all P ≥ .12). One thigh graft (2%) and five HeRO (15%) grafts failed primarily. In the intention-to-treat analysis, patency durations were significantly longer in the thigh grafts (all log-rank P ≤ .01). Point estimates of primary patency at 6 months, 1 year, and 3 years were 61%, 46%, and 4% for the thigh grafts and 25%, 15%, and 6% for the HeRO grafts. Point estimates of assisted primary patency at 6 months, 1 year, and 3 years were 75%, 66%, and 54% for the thigh grafts and 41%, 30%, and 10% for the HeRO grafts. Point estimates of secondary patency at 6 months, 1 year, and 3 years were 88%, 88%, and 70% for the thigh grafts and 53%, 43%, and 12% for the HeRO grafts. There were no differences in ischemic (P = .63) or infectious (P = .79) complications between the groups. Multivariable logistic regression demonstrated that after adjusting for follow-up time, HeRO grafts were associated with an increased number of interventions (P = .03).
  
  
  CONCLUSIONS
  Thigh grafts have significantly better primary, assisted primary, and secondary patency compared with HeRO grafts. There is no significant difference between thigh grafts and HeRO grafts in ischemic or infectious complications. Our logistic regression model demonstrated an association between HeRO grafts and an increased number of interventions to maintain or restore patency. Although HeRO grafts may extend the use of the upper extremity, thigh grafts provide a more durable option for chronic hemodialysis.
authors.affiliation: Department of Surgery, Vanderbilt University Medical Center, Nashville, Tenn. Electronic address: evan.r.brownie@vanderbilt.edu.
authors.forename: Evan R
authors.initials: ER
authors.lastname: Brownie
authors.affiliation: Department of Surgery, Vanderbilt University Medical Center, Nashville, Tenn.
authors.forename: Clark D
authors.initials: CD
authors.lastname: Kensinger
authors.affiliation: Departments of Surgery and Biostatistics, Vanderbilt University Medical Center, Nashville, Tenn.
authors.forename: Irene D
authors.initials: ID
authors.lastname: Feurer
authors.affiliation: Department of Surgery, Vanderbilt University Medical Center, Nashville, Tenn.
authors.forename: Derek E
authors.initials: DE
authors.lastname: Moore
authors.affiliation: Department of Surgery, Vanderbilt University Medical Center, Nashville, Tenn.
authors.forename: David
authors.initials: D
authors.lastname: Shaffer
mesh_terms: D000328:Adult; D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects / Q000295:instrumentation*; D001807:Blood Vessel Prosthesis / Q000009:adverse effects; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation*; D057286:Electronic Health Records; D005260:Female; D005263:Femoral Artery / Q000503:physiopathology / Q000601:surgery*; D005268:Femoral Vein / Q000503:physiopathology / Q000601:surgery*; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D006801:Humans; D057194:Intention to Treat Analysis; D053208:Kaplan-Meier Estimate; D007676:Kidney Failure, Chronic / Q000628:therapy*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016016:Proportional Hazards Models; D011474:Prosthesis Design; D016459:Prosthesis-Related Infections / Q000382:microbiology / Q000628:therapy; D006435:Renal Dialysis; D019233:Retreatment; D012189:Retrospective Studies; D012307:Risk Factors; D013714:Tennessee; D013848:Thigh / Q000098:blood supply*; D013997:Time Factors; D016896:Treatment Outcome; D034941:Upper Extremity / Q000098:blood supply*; D014654:Vascular Patency