Outcome of surgery for vascular access in patients commencing haemodialysis

Abstract

Objective: assessment of surgical vascular access procedures for haemodialysis. Design: retrospective cohort audit. Materials and methods: secondary patency was calculated from surgery until access failure, death, transplant, conversion to peritoneal dialysis, or loss to follow-up. All surgical procedures including immediate failures and failures to mature fistulae were included but not radiological interventions. Results: four hundred and forty-five operations were undertaken in 197 patients over 87 months comprising 273 access creations and 172 revisions. Median follow-up was 26 months with a mortality of 9.4 deaths per 100 patient-years including eight perioperative deaths. Autogenous access was created in 147 (75%) patients with 142 based on the radial artery whilst 50 prosthetic grafts including 46 PTFE grafts and 40 forearm loops were placed. Patients receiving grafts were more likely to be older, female and die in follow-up. Grafts had higher patencies of 89, 75 and 68% at 1, 2 and 4 years, respectively compared to 69, 63 and 55% for autogenous access. This difference was significant (p = 0.049) when the effects of the presence of diabetes and peripheral arterial disease were accounted for but more frequent revisions were required. The final access placed was autogenous in 110 (56%) and prosthetic in 87 (44%) patients. Conclusions: in our surgical unit, there was high secondary patency including for prosthetic grafts, high autogenous utilisation and relatively infrequent reintervention.