SS14 - Outcomes of upper arm arteriovenous graft versus brachiobasilic fistula for hemodialysis access

Objectives: Primary arteriovenous access such as radiocephalic and brachiocephalic fistulas are initial choices for creating vascular access in dialysis patients. When neither of these choices is an option, upper arm arteriovenous graft or brachiobasilic transposition is recommended. While primary fistula is better than prosthetic graft for suitable patients, there is little data to guide the best treatment strategy in the absence of suitable vein for primary access creation. This study identifies factors that influence patency rates and compares outcomes of patients treated with brachiobasilic fistula versus upper arm graft in patients who have failed forearm access or are not candidates for primary access.

Methods: A prospectively maintained database of patients with dialysis-dependent renal failure from 2010 to 2022 was analyzed. Primary, primary assisted, and secondary patency rates were calculated. Incidence rates of complications and reinterventions were compared.

Results: There were 155 patients with brachiobasilic fistulas and 82 patients with upper arm grafts. The graft group was older (70.1 +/- 15.5 vs 63.1 +/- 14.7 years, p = 0.0005) and had a higher incidence of pacemakers (13.4% vs 3.2%, p = 0.005). Brachiobasilic fistulas had higher 6-month primary-assisted patency (77.4 vs 65.9%, p = 0.05), but secondary patency rates were better for upper arm grafts at 6 and 12 months (87.8% vs 76.8%, p =0.05; 81.7% vs 70.3%, p = 0.05) with no statistically significant difference at 2 years (67.1% vs 54.2%, p = 0.07). Access complications of non-maturation and aneurysm were higher in basilic vein transposition (17.4% vs 1.2%, p < 0.0001; 18.1% vs 6.1%, p = 0.01). Grafts had higher rates of occlusion (54.9% vs 26.5%, p = 0.001). In terms of interventions, upper arm grafts had higher rates of thrombectomy (37.8% vs 6.5%, p < 0.0001), but there was no difference seen in angioplasty/stent, surgical revision, or procedures for steal syndrome. Basilic vein transpositions had longer time to cannulation (87.5 vs 31.6 days, p < 0.0001) and higher number of procedures to aid maturity (0.5 vs 0.09, p < 0.0001).

Conclusions: In this retrospective analysis when forearm access or primary arteriovenous access is not an option, basilic vein transposition and upper arm grafts have fairly equivalent primary assisted patency with slightly worse secondary patency rates in fistulas compared to arteriovenous grafts. Basilic fistulas also had longer time to cannulation and more procedures to aid maturity.