title: A randomized controlled trial and cost-effectiveness analysis of early cannulation arteriovenous grafts versus tunneled central venous catheters in patients requiring urgent vascular access for hemodialysis.
abstract: OBJECTIVE
  Early cannulation arteriovenous grafts (ecAVGs) are proposed as an alternative to tunneled central venous catheters (TCVCs) in patients requiring immediate vascular access for hemodialysis (HD). We compared bacteremia rates in patients treated with ecAVG and TCVC.
  
  
  METHODS
  The study randomized 121 adult patients requiring urgent vascular access for HD in a 1:1 fashion to receive an ecAVG with or without (+/-) an arteriovenous fistula (AVF; n = 60) or TCVC+/-AVF (n = 61). Patients were excluded if they had active systemic sepsis, no anatomically suitable vessels, or an anticipated life expectancy <3 months. The primary end point was the culture-proven bacteremia rate at 6 months, with the trial powered to detect a reduction in bacteremia from 24% to 5% (α = .05, β = .8). Secondary end points included thrombosis, reintervention, and mortality. A cost-effectiveness analysis was also performed.
  
  
  RESULTS
  Culture-proven bacteremia developed in 10 patients (16.4%) in the TCVC arm ≤6 months compared with two (3.3%) in the ecAVG+/-AVF arm (risk ratio, 0.2; 95% confidence interval, 0.12-0.56; P = .02). Mortality was also higher in the TCVC+/-AVF cohort (16% [n = 10] vs 5% [n = 3]; risk ratio, 0.3; 95% CI, 0.08-0.45; P = .04). The difference in treatment cost between the two arms was not significant (£11,393 vs £9692; P = .24).
  
  
  CONCLUSIONS
  Compared with TCVC+/-AVF, a strategy of ecAVG+/-AVF reduced the rate of culture-proven bacteremia and mortality in patients requiring urgent vascular access for HD. The strategy also proved to be cost-neutral.
authors.affiliation: Department of Renal Surgery, Queen Elizabeth University Hospital, Glasgow, United Kingdom; College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom. Electronic address: emmaaitken@nhs.net.
authors.forename: Emma
authors.initials: E
authors.lastname: Aitken
authors.affiliation: Department of Nephrology, Queen Elizabeth University Hospital, Glasgow, United Kingdom.
authors.forename: Peter
authors.initials: P
authors.lastname: Thomson
authors.affiliation: Department of Renal Surgery, Queen Elizabeth University Hospital, Glasgow, United Kingdom.
authors.forename: Leigh
authors.initials: L
authors.lastname: Bainbridge
authors.affiliation: Department of Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, United Kingdom.
authors.forename: Ram
authors.initials: R
authors.lastname: Kasthuri
authors.affiliation: W. L. Gore and Associates, Inc, Flagstaff, Ariz.
authors.forename: Belinda
authors.initials: B
authors.lastname: Mohr
authors.affiliation: Department of Renal Surgery, Queen Elizabeth University Hospital, Glasgow, United Kingdom; College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom.
authors.forename: David
authors.initials: D
authors.lastname: Kingsmore
mesh_terms: D000328:Adult; D000368:Aged; D016470:Bacteremia / Q000175:diagnosis / Q000191:economics / Q000382:microbiology; D001807:Blood Vessel Prosthesis / Q000009:adverse effects / Q000191:economics*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000191:economics* / Q000295:instrumentation / Q000401:mortality; D055499:Catheter-Related Infections / Q000175:diagnosis / Q000191:economics / Q000382:microbiology; D002404:Catheterization / Q000009:adverse effects / Q000191:economics*; D002405:Catheterization, Central Venous / Q000009:adverse effects / Q000191:economics* / Q000295:instrumentation / Q000401:mortality; D002408:Catheters, Indwelling / Q000009:adverse effects / Q000191:economics*; D062905:Central Venous Catheters / Q000009:adverse effects / Q000191:economics*; D003362:Cost-Benefit Analysis; D005260:Female; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011446:Prospective Studies; D016459:Prosthesis-Related Infections / Q000175:diagnosis / Q000191:economics / Q000382:microbiology; D006435:Renal Dialysis / Q000191:economics*; D012307:Risk Factors; D012606:Scotland; D013997:Time Factors; D016896:Treatment Outcome