RS18 - Transposed Brachial-Basilic Fistula vs Arteriovenous Graft as Tertiary Hemodialysis Access in Elderly Patients

Objectives: People over the age of 65 now account for 52% of hemodialysis (HD) patients in the US. Well-functioning vascular access is a crucial for successful HD therapy. While radiocephalic and brachiocephalic arteriovenous fistulas remain preferred choices as primary and secondary vascular access in patients with adequate superficial veins, in those without, the choice of optimal tertiary access between arteriovenous graft (AVG) and transposed brachiobasilic fistula (BVT) remains unclear, especially for elderly patients. The goal of this study was to compare outcomes of AVGs vs. BVTs in patients over the age of 65.

Methods: A retrospective cohort study was performed comparing outcomes of patient ≥65 years of age that underwent BVT vs AVG creation between 2015 and 2021 in an academic medical center. Outcomes were maturation, rates of interventions for maturation, time to maturation and catheter-free dialysis, 1-year primary and cumulative patency, incidence rates of access-related complications (thrombosis, infection, steal) and reinterventions to maintain patency. Access was considered matured if successfully used for dialysis on 3 consecutive sessions without interventions. Time to maturation was defined as the interval between access creation and maturation. Time to catheter-free dialysis was defined as the interval between access creation and central venous catheter removal. Patients who were not on HD were excluded from the analysis.

Results: A total of 203 patients were included in the study: 66 with BVTs and 137 with AVGs. AVGs had higher maturation rates as compared to BVTs, 88% vs.71%, p=0.003. Less AVGs required interventions to assist maturation (OR= 0.28, 95%CI:0.14-0.55, p< 0.001). Median time to maturation (28 days vs 104 days, p< 0.001) and median time to catheter-free dialysis (45 days vs 130 days, p< 0.001) were significantly shorter in the AVG group compared to the BVTs. 1-year primary patency (42% in BVT vs. 47% in AVG group, p=0.8) and cumulative patency (66% in BVT vs. 79% in AVG group, p=0.3) were similar in both groups. The incidence rate of complications was 0.38/patient-year in AVG group vs. 0.17/patient-year in BVT group, p=0.003. The rates of reinterventions were similar in both groups, 0.92 for AVGs and 1.1 for BVTs, (p=0.3).

Conclusions: BVT has worse maturation rates, require more interventions for maturation, has longer time to maturation with similar long-term patency and number of interventions to maintain patency when compared with AVG. Our data suggests that AVGs may be preferred tertiary HD access in elderly patients.