December 12, 2008

Comparison of the Efficacy of Upper Arm Transposed Arteriovenous Fistulae and Upper Arm Prosthetic Grafts: Analysis of 358 Matched Procedures

Karen Woo¹, Tina Ng², Gheorghe Doros, PhD³, Alik Farber³.
¹Scripps/UCSD, La Jolla, CA, USA, ²Cedars-Sinai Medical Center, Los Angeles, CA, USA, ³Boston University, Boston, MA, USA.

OBJECTIVES:
Direct comparison of transposed arteriovenous fistulas (tAVF) and arteriovenous grafts (AVG) has been hampered by inherent differences in patient characteristics between tAVF and AVG groups. Controlling for these variables by matching, we evaluated our extensive experience with upper arm tAVF and upper arm prosthetic AVG in order to determine which procedure is most efficacious.
METHODS:
A retrospective review of upper arm tAVF and AVG was performed. Transposed fistulae consisted of 119 basilic vein and 71 cephalic vein transpositions which were found to have similar demographic parameters, complication rates, and patency rates. These 190 upper arm tAVF were group matched for age, gender, race, diabetes, and history of previous failed access with 168 AVG chosen from a pool of 476 concurrently performed AVG procedures. Complication, patency, and reintervention rates were compared and multivariate analysis was performed.
RESULTS:
Mean follow up was 29.1 months. There was no significant difference in 30 day mortality, 24 hour thrombosis, bleeding requiring exploration, and ischemic steal requiring intervention between the tAVF and AVG groups. Significantly more AVG developed infection requiring operative exploration than tAVF (7.9% vs 1.6%, respectively. P=0.004). Primary patency for tAVF was significantly higher than for AVG: 48% vs 14% at 5 years (p<.0001). Secondary patency rate for tAVF was significantly higher than for AVG: 57% vs 21% at 5 years (p<0.0001). Nine percent of tAVF compared to 53% of AVG required one or more revisions to maintain secondary patency, (p<0.0001). Multivariate analysis revealed that presence of a tAVF decreased the risk of primary (HR 0.47, 95% CI 0.35 -0.64, p <.0001) and secondary failure (HR 0.59, 95%CI 0.42-0.81, p =0.0001).
CONCLUSIONS:
Transposed arteriovenous fistulas have significantly higher primary and secondary patency rates, require fewer revisions and are less likely to develop a significant infection than AVG. This data strongly supports the contention that as long as a patient is a candidate for a tAVF based on anatomic criteria, a tAVF should always be considered before an AVG.

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