Temporal Trends in Hemodialysis Access Creation During the Fistula First Era.

OBJECTIVES: Although forearm arteriovenous fistulas (AVFs) are the preferred initial vascular access for hemodialysis based on national guidelines, there are no population-level studies evaluating trends in creation of forearm versus upper arm AVFs and arteriovenous grafts (AVGs). The purpose of this study was to report temporal trends in first-time permanent hemodialysis access type, and to assess the effect of national initiatives on rates of AVF placement.

METHODS: Retrospective cross-sectional study (2012 to 2022) utilizing the Vascular Quality Initiative (VQI) database. All patients older than 18 years with creation of first-time upper extremity surgical hemodialysis access were included. Anatomic location of the AVF or AVG (forearm versus upper arm) was defined based on inflow artery, outflow vein, and presumed cannulation zone. Primary analysis examined temporal trends in rates of forearm versus upper arm AVF and AVG using time series analyses (modified Mann-Kendall test). Subgroup analyses examined rates of access configuration stratified by age, sex, race, dialysis and socioeconomic status. Interrupted time series analysis was performed to assess the effect of the 2015 Fistula First Catheter Last (FFCL) initiative on rates of AVF.

RESULTS: Of the 52,170 accesses, 57.9% were upper arm AVFs, 25.2% forearm AVFs, 15.4% upper arm AVGs, and 1.5% forearm AVGs. From 2012 to 2022, there was no significant change in overall rates of forearm or upper arm AVFs. There was a numerical increase in upper arm AVGs (13.9 to 18.2 per 100 , p = 0.09) , while forearm AVGs significantly declined (1.8 to 0.7 per 100, p=0.02). In subgroup analyses, we observed a decrease in forearm AVFs among men (33.1 to 28.7 per 100, p=0.04) and disadvantaged (Area Deprivation Index Percentile ≥ 50) patients (29.0 to 20.7 per 100,p=0.04), while female (17.2 to 23.1 per 100, p=.03), black (15.6 to 24.5 per 100, p<0.01), elderly (age≥80) (18.7 to 32.5 per 100, p< 0.01), and disadvantaged (13.6 to 20.5 per 100,p<0.01) patients had a significant increase in upper arm AVGs. The FFCL initiative had no effect on the rate of AVF placement (83.2 to 83.7 per 100, p=0.37).

CONCLUSION: Despite national initiatives to promote autogenous vascular access, the rates of first-time AVFs have remained relatively constant with forearm AVF only representing one-quarter of all permanent surgical accesses. Furthermore, elderly, black, female, and disadvantaged patients saw an increase in upper arm AVGs. Further efforts to elucidate factors associated with forearm AVF placement as well as potential physician, center, and regional variation is warranted.