TITLE: Long-Term Functional Patency and Cost-Effectiveness of Arteriovenous Fistula Creation under Regional Anesthesia: a Randomized Controlled Trial.
BACKGROUND: Regional anesthesia improves short-term blood flow through arteriovenous fistulas (AVFs). We previously demonstrated that, compared with local anesthesia, regional anesthesia improves primary AVF patency at 3 months.
METHODS: To study the effects of regional versus local anesthesia on longer-term AVF patency, we performed an observer-blinded randomized controlled trial at three university hospitals in Glasgow, United Kingdom. We randomly assigned 126 patients undergoing primary radiocephalic or brachiocephalic AVF creation to receive regional anesthesia (brachial plexus block; 0.5% L-bupivacaine and 1.5% lidocaine with epinephrine) or local anesthesia (0.5% L-bupivacaine and 1% lidocaine). This report includes findings on primary, functional, and secondary patency at 12 months; reinterventions; and additional access procedures (primary outcome measures were previously reported). We analyzed data by intention to treat, and also performed cost-effectiveness analyses.
RESULTS: At 12 months, we found higher primary patency among patients receiving regional versus local anesthesia (50 of 63 [79%] versus 37 of 63 [59%] patients; odds ratio [OR], 2.7; 95% confidence interval [95% CI], 1.6 to 3.8; P=0.02) as well as higher functional patency (43 of 63 [68%] versus 31 of 63 [49%] patients; OR, 2.1; 95% CI, 1.5 to 2.7; P=0.008). In 12 months, 21 revisional procedures, 53 new AVFs, and 50 temporary dialysis catheters were required. Regional anesthesia resulted in net savings of £195.10 (US$237.36) per patient at 1 year, and an incremental cost-effectiveness ratio of approximately £12,900 (US$15,694.20) per quality-adjusted life years over a 5-year time horizon. Results were robust after extensive sensitivity and scenario analyses.
CONCLUSIONS: Compared with local anesthesia, regional anesthesia significantly improved both primary and functional AVF patency at 1 year and is cost-effective.
SOURCE: Aitken E, Kearns R, Gaianu L, et al. Long-Term Functional Patency and Cost-Effectiveness of Arteriovenous Fistula Creation under Regional Anesthesia: a Randomized Controlled Trial[J]. J Am Soc Nephrol, 2020, 31(8):1871-1882. DOI: 10.1681/ASN.2019111209.
背景：区域麻醉可改善动静脉内瘘（AVF）的短期血流。我们先前证明，与局部麻醉相比，区域麻醉可改善3个月时原发性AVF的通畅性。
方法：为了研究区域麻醉与局部麻醉对AVF长期通畅的影响，我们在英国格拉斯哥的三所大学医院进行了一项观察者盲法的随机对照试验。我们随机分配126例接受原发性放射头或头颅性AVF手术的患者接受区域麻醉（臂丛神经阻滞; 0.5％L-布比卡因和1.5％利多卡因加肾上腺素）或局部麻醉（0.5％L-布比卡因和1％利多卡因）。该报告包括12个月时一期，功能和二期通畅的发现；再干预；以及其他访问程序（先前已报告了主要结果指标）。我们按治疗目的分析了数据，并进行了成本效益分析。
结果：在12个月时，我们发现接受区域麻醉的患者与局部麻醉相比，通畅率更高（63名患者中的50名[79％]与63名患者中的37名[59％]；比值比[OR]为2.7； 95％置信区间[95％ CI]，从1.6到3.8； P = 0.02）以及更高的功能通畅性（63例中的43人[68％]，而63例中的31人[49％]； OR，2.1； 95％CI，1.5到2.7； P = 0.008）。在12个月内，21次翻修手术，53个新建AVF和50个临时透析导管。区域麻醉在1年内使每位患者净节省195.10（US $ 237.36），在5年的时间范围内，每质量调整生命年的成本效益比增加约12,900（US $ 15,694.20）。经过广泛的敏感性和背景分析后，结果是可靠的。
结论：与局部麻醉相比，区域麻醉在1年时可显着改善一期和功能性AVF的通畅率，并且具有成本效益。
启发：从长期观察来看，臂丛神经阻滞在AVF建立中有其优势，即改善通畅率，又节约成本。
