Brachiocephalic and Radiocephalic Arteriovenous Fistulas in Patients with Tunneled Dialysis Catheters Have Similar Outcomes.

OBJECTIVES: Patients with tunneled dialysis catheters (TDC) have a time sensitive need for a functional permanent access due to high risk of catheter-associated morbidity. Brachiocephalic arteriovenous fistulas (BCF) have been reported to have higher maturation and patency compared to radiocephalic arteriovenous fistulas (RCF), although more distal creation is encouraged when possible. However, this may lead to a delay in establishing permanent vascular access and ultimately TDC removal. Our goal was to assess short-term outcomes after BCF and RCF creation for patients with concurrent TDCs to see if these patients would potentially benefit more from an initial brachiocephalic access to minimize TDC dependence.

METHODS: The Vascular Quality Initiative hemodialysis registry was analyzed from 2011-2018. Patient demographics, comorbidities, access type, and short-term outcomes including occlusion, reinterventions, and access being used for dialysis were assessed.

RESULTS: There were 2,359 patients with TDC, of which 1389 (58.9%) underwent BCF creation and 970 (41.1%) underwent RCF creation. Average patient age was 59 years and 62.8% were male. Compared with RCF, those with BCF were more often older, of female sex, obese, non-independently ambulatory, have commercial insurance, diabetes, coronary artery disease, chronic obstructive pulmonary disease, be on anticoagulation, and have a cephalic vein diameter of ≥ 3 mm (all P<.05). Kaplan-Meier analysis for 1-year outcomes for BCF and RCF, respectively, showed that primary patency was 45% vs. 41.3% (P=.88), primary assisted patency was 86.7% vs. 86.9% (P=.64), freedom from reintervention was 51.1% vs. 46.3% (P=.44), and survival was 81.3% vs. 84.9% (P=.02). Multivariable analysis showed that BCF was comparable to RCF with respect to primary patency loss (HR 1.11, 95% CI .91 - 1.36, P=.316), primary assisted patency loss (HR 1.11 95% CI .72 - 1.29, P=.66) and reintervention (HR 1.01, 95% CI .81 - 1.27, P=.92). Access being used at 3 months was similar but trending towards RCF being used more often (OR .7, 95% CI . 49 - 1, P=.05).

CONCLUSION: BCFs do not have superior fistula maturation and patency compared to RCFs in patients with concurrent TDCs. Creation of radial access, when possible, does not prolong TDC dependence.