title: Second vascular access after failure of the first fistula in the elderly .
abstract: BACKGROUND
  In patients with failure of an initial arteriovenous fistula (AVF), a subsequent vascular access is needed before hemodialysis (HD) initiation.
  
  
  METHODS
  To assess the optimal access strategy after a failed AVF, we linked data from the US Renal Data System with Medicare claims data identifying 21,436 patients ≥ 67 years old who started HD between January 1, 2005, and December 31, 2008, with an AVF placed as their first predialysis access. Of the 10,568 subjects whose AVF failed, 1,796 patients had an AVF placed as a second access predialysis (AVF2 group) and 399 patients had an arteriovenous graft placed as a second access predialysis (AVG2 group). Second access success was defined as HD initiation for the first HD session using this access avoiding need for a catheter.
  
  
  RESULTS
  The mean age for AVF2 and AVG2 groups was 75.9 ± 6.0 and 75.9 ± 5.9 years with a significantly greater percentage of men and whites in the AVF2 group and women and blacks in the AVG2 group. Overall, 53% of AVF2 group initiated dialysis using AVF2, and 66% of AVG2 group started dialysis using AVG2 (p < 0.001). The following variables were found to be associated with AVF2 failure: female gender, peripheral vascular disease (PVD), interventional procedures, and the absence of pre-ESRD nephrology care. AVG2 failure was associated with white race, lower body mass index (BMI), and the absence of pre-ESRD (end-stage renal disease) nephrology care.
  
  
  CONCLUSIONS
  Since the success rate to avoid the use of a catheter was significantly higher in the AVG2 group than in the AVF2 group, an AVG may be a preferable choice of second access in certain patients, especially in females, blacks and those with PVD. .
authors.forename: Tammy
authors.initials: T
authors.lastname: Hod
authors.forename: Alexander S
authors.initials: AS
authors.lastname: Goldfarb-Rumyantzev
authors.forename: Bhanu K
authors.initials: BK
authors.lastname: Patibandla
authors.forename: Akshita
authors.initials: A
authors.lastname: Narra
authors.forename: Robert S
authors.initials: RS
authors.lastname: Brown
mesh_terms: D001741:Black or African American / Q000706:statistics & numerical data; D000368:Aged; D000369:Aged, 80 and over; D001166:Arteriovenous Shunt, Surgical / Q000706:statistics & numerical data*; D015992:Body Mass Index; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D008297:Male; D009398:Nephrology / Q000706:statistics & numerical data; D016491:Peripheral Vascular Diseases / Q000150:complications; D006435:Renal Dialysis / Q000706:statistics & numerical data*; D012086:Reoperation / Q000706:statistics & numerical data; D012737:Sex Factors; D017211:Treatment Failure; D062666:Vascular Access Devices / Q000706:statistics & numerical data; D058017:Vascular Grafting / Q000706:statistics & numerical data; D044465:White People / Q000706:statistics & numerical data