TITLE: Inferiority of arteriovenous grafts, in comparison to autogenous fistulas, is underestimated by standard survival measures alone

BACKGROUND: It has been argued that a prosthetic arteriovenous graft (AVG) is a reasonable alternative to an arteriovenous fistula (AVF) for dialysis. We aimed to compare the patency rates and requirements for the intervention of newly formed AVF and AVG.

METHODS: A retrospective analysis was undertaken of AVF and AVG formed between 1 January 2013 and 31 December 2015 at two tertiary referral centres and followed up until 31 December 2017. Outcome measures included successful use for dialysis, patency rates and the number of interventions required to maintain dialysis access per patient-year (PPY).

RESULTS: Four hundred and seventy AVF and 92 AVG were constructed. Of 470 AVF, 324 (68.9%) were used compared to 80 of 92 (87%) AVG. One year assisted primary patency of AVF was 75% (confidence interval 71-79%) compared to 47% (confidence interval 36-57%) for AVG. Secondary patency rates for AVF at 1, 2 and 3 years were 77%, 71% and 69%, respectively. At the same time points, secondary patency rates for AVG were 77%, 60% and 46%, respectively (log rank P = 0.034). AVG required 2.4 times the number of interventions PPY than AVF. Surgical thrombectomy of AVG was at a rate of 0.49 PPY compared with 0.042 PPY for AVF.

CONCLUSION: AVG have a substantially higher rate of thrombosis than AVF, evident from early in the life of the graft. AVF demonstrate superior patency rates to AVG throughout the life of the access, with far fewer interventions PPY than grafts.

SOURCE: Thwaites SE, Holt SG, Yii MK. Inferiority of arteriovenous grafts, in comparison to autogenous fistulas, is underestimated by standard survival measures alone[J]. ANZ J Surg, 2021, 91(1-2):162-167. DOI: 10.1111/ans.16472. 

背景:有人认为人造移植物血管(AVG)是替代动静脉内瘘(AVF)进行透析的合理选择。我们的目的是比较新建立的AVF和AVG的通畅率和介入需求。

方法:对2013年1月1日至2015年12月31日在两个三级转诊中心形成的AVF和AVG进行回顾性分析,并随访至2017年12月31日。结局评估包括透析的成功使用、通畅率和每年维持透析通道所需的干预次数(PPY)。

结果:共构建AVF 470个,AVG 92个。在470个AVF中,324个(68.9%)被使用,而92个AVG中有80个(87%)被使用。AVF的一年辅助初级通畅率为75%(置信区间71-79%),而AVG为47%(置信区间36-57%)。AVF术后1、2、3年二级通畅率分别为77%、71%和69%。在同一时间点,AVG组的二次通畅率分别为77%、60%和46%(对数等级P=0.034)。AVG需要的PPY干预次数是AVF的2.4倍。AVG的手术取栓率为0.49PPY,而AVF的手术取栓率为0.042 PPY。

结论:AVG的血栓发生率明显高于AVF,从移植物的早期就可以明显看出这一点。AVF在整个通路的生命周期中显示出对AVG的卓越通畅率,干预PPY比移植物血管少得多。

启发:“优先使用自体动静脉内瘘”是有一定依据的(若有前瞻性的,就更好了),通路医生应该合理评估患者血管情况,为长期透析的需要着眼,给予适合的通路选择方案。