title: Access-related hand ischemia and the Hemodialysis Fistula Maturation Study.
abstract: OBJECTIVE
  Access-related hand ischemia (ARHI) is a major complication after hemodialysis access construction. This study was designed to prospectively describe its incidence, predictors, interventions, and associated access maturation.
  
  
  METHODS
  The Hemodialysis Fistula Maturation Study is a multicenter prospective cohort study designed to identify predictors of autogenous arteriovenous access (arteriovenous fistula [AVF]) maturation. Symptoms and interventions for ARHI were documented, and participants who received interventions for ARHI were compared with other participants using a nested case-control design. Associations of ARHI with clinical, ultrasound, vascular function, and vein histologic variables were each individually evaluated using conditional logistic regression; the association with maturation was assessed by relative risk, Pearson χ(2) test, and multiple logistic regression.
  
  
  RESULTS
  The study cohort included 602 participants with median follow-up of 2.1 years (10th-90th percentiles, 0.7-3.5 years). Mean age was 55.1 ± 13.4 (standard deviation) years; the majority were male (70%), white (47%), diabetic (59%), smokers (55%), and on dialysis (64%) and underwent an upper arm AVF (76%). Symptoms of ARHI occurred in 45 (7%) participants, and intervention was required in 26 (4%). Interventions included distal revascularization with interval ligation (13), ligation (7), banding (4), revision using distal inflow (1), and proximalization of arterial inflow (1). Interventions were performed ≤7 days after AVF creation in 4 participants (15%), between 8 and 30 days in 6 (23%), and >30 days in 16 (63%). Female gender (odds ratio, 3.17; 95% confidence interval, 1.27-7.91; P = .013), diabetes (13.62 [1.81-102.4]; P = .011), coronary artery disease (2.60 [1.03-6.58]; P = .044), higher preoperative venous capacitance (per %/10 mm Hg, 2.76 [1.07-6.52]; P = .021), and maximum venous outflow slope (per [mL/100 mL/min]/10 mm Hg, 1.13 [1.03-1.25]; P = .011) were significantly associated with interventions; a lower carotid-femoral pulse wave velocity and the outflow vein diameter in the early postoperative period (days 0-3) approached significance (P < .10). Intervention for ARHI was not associated with AVF maturation failure (unadjusted risk ratio, 1.18 [0.69-2.04], P = .56; adjusted odds ratio, 0.97 [0.41-2.31], P = .95).
  
  
  CONCLUSIONS
  Remedial intervention for ARHI after AVF construction is uncommon. Diabetes, female gender, capacitant outflow veins, and coronary artery disease are all associated with an increased risk of intervention. These higher risk patients should be counseled preoperatively, their operative plans should be designed to reduce the risk of hand ischemia, and they should be observed closely.
authors.affiliation: Division of Vascular Surgery, University of Florida College of Medicine, Gainesville, Fla. Electronic address: thomas.huber@surgery.ufl.edu.
authors.forename: Thomas S
authors.initials: TS
authors.lastname: Huber
authors.affiliation: Department of Quantitative Health Sciences, Learner Research Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.
authors.forename: Brett
authors.initials: B
authors.lastname: Larive
authors.affiliation: Department of Quantitative Health Sciences, Learner Research Institute, 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: Department of Quantitative Health Sciences, Learner Research Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.
authors.forename: Milena K
authors.initials: MK
authors.lastname: Radeva
authors.affiliation: 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: Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, Mass.
authors.forename: Alik M
authors.initials: AM
authors.lastname: Farber
authors.affiliation: Division of Vascular Surgery, University of Florida College of Medicine, Gainesville, Fla.
authors.forename: Scott A
authors.initials: SA
authors.lastname: Berceli
mesh_terms: D000328:Adult; D000368:Aged; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects*; D016022:Case-Control Studies; D016009:Chi-Square Distribution; D005260:Female; D006225:Hand / Q000098:blood supply*; D006801:Humans; D015994:Incidence; D007511:Ischemia / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000503:physiopathology / Q000628:therapy; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D018579:Patient Selection; D011446:Prospective Studies; D006435:Renal Dialysis; D019233:Retreatment; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology