Vascular access in hemodialysis patients older than 80 years Oded Olsha, MB, BS, Jamal Hijazi, MD, Ilya Goldin, MD, and David Shemesh, MD, Jerusalem, Israel Objective: There is a worldwide surge in numbers of elderly people requiring hemodialysis accompanying the prevailing increase in longevity. There is a trend for central venous catheters to be preferentially placed in elderly patients, whereas others recommend routine use of grafts for surgical access. In our center, age has not been a consideration in deciding to construct arteriovenous access for hemodialysis. We reviewed our experience with arteriovenous access surgery in all hemodialysis patients aged 80 years and older to determine if this approach is justified in terms of patency and life expectancy. Methods: A retrospective study was made of all patients aged 80 years and older who had surgery from January 2005 to December 2009 at our national vascular access referral center. All patients had preoperative mapping and had fistula construction if the vein size was at least 3 mm. Otherwise they had brachiobasilic or brachioaxillary grafts. All patients had routine access surveillance by Doppler ultrasound (duplex) and physical examination at regular intervals, and interventions were carried out according to the findings. Type of access, success rate, maturation, primary and secondary patency, and patient survival in the age group older than 80 years were noted. Results: During the study period, 134 patients had 146 new accesses. There were 128 autogenous accesses (30 forearm, 91 upper arm, and seven transposed basilic veins) and 18 prosthetic accesses. Overall primary patency was 39%, 33%, and 23% at 12, 24, and 36 months. Secondary patency was 92%, 83%, and 77% at 12, 24, and 36 months. There was no significant difference in patency between the different types of accesses and between diabetic and nondiabetic patients. Eleven upper arm and four forearm fistulas had delayed maturation or nonmaturation. The relative risk for delayed maturation or nonmaturation of forearm fistulas (13.3%) compared with brachial-cephalic fistula (12.1%) was 1.1030 (95% confidence interval, 0.3973-3.204; P [ .8571). Median patient survival was 38 months, with 49 dying during follow-up. Conclusions: Contrary to recent recommendations favoring grafts for hemodialysis in patients older than 80 years, most elderly patients in this study were found to have vasculature that was suitable for autogenous access construction, with patency rates similar to those of their younger counterparts when adequate preoperative planning and postoperative maintenance were carried out. Age alone should not disqualify patients older than 80 years from access surgery for hemodialysis, nor should age disqualify these patients from the Fistula First Initiative. (J Vasc Surg 2014;-:1-7.)
Renal replacement therapy has special implications for older patients, who constitute the fastest growing sector of the incident end-stage renal disease population.1 The increased life expectancy of patients with chronic illnesses has resulted in a considerable increase in the number of older patients requiring dialysis. Improvements in dialysis care have also contributed to the increasing numbers of older dialysis patients. Increasing age is related to lower maturation rates, poorer fistula patency, and lower life expectancy of the hemodialysis patient. Older hemodialysis patients are more
From the Department of Surgery and Vascular Access Center, Shaare Zedek Medical Center (affiliated with the Faculty of Health Sciences, Hebrew University). Author conflict of interest: D.S. receives consulting fees from W. L. Gore and Associates and from Bard Peripheral Vascular. Presented at the Vascular Access Society 7th International Congress, May 5-7, 2011, Istanbul, Turkey. Reprint requests: David Shemesh, MD, Vascular Access Center, Department of Surgery, Shaare Zedek Medical Center, PO Box 3235, Jerusalem 91031, Israel (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2014 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2014.07.005
likely than younger individuals to have poor-quality arm veins because of prior medical interventions and to have atheroma or medial calcification affecting their radial or brachial arteries.2 Such patients are more susceptible to symptomatic steal syndrome because of inflow stenosis. Because of the presence of multiple comorbidities in these elderly patients, any disturbance of this delicate equilibrium is likely to lead to serious complications. For these reasons, many octogenarian patients have hemodialysis access through a tunneled cuffed catheter.3 However, one study has shown that patients older than 75 years with autogenous vascular access can have patency that is similar to that of younger patients.4 Notwithstanding current recommendations, there has been a recent trend away from the Fistula First Initiative in the age group older than 80 years,5 with age being one of the four predictive factors used by Lok et al to predict failure to mature in fistulas.6 In our center, the patient’s age has not been a consideration in the decision to construct arteriovenous hemodialysis access, with the oldest patient to have access surgery aged 94 years. We studied patients older than 80 years who had hemodialysis access construction in our center to determine the type of access that was constructed, the success rate of the operations, the maturation rates and the patency of the accesses, and the mortality rates in these older patients. 1
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METHODS Study design. This was a retrospective study of patients in our hemodialysis access registry that is maintained separately from hospital records and includes all patients undergoing hemodialysis access construction, including any subsequent follow-up and intervention. The study was approved by the Ethics Committee of the Shaare Zedek Medical Center and exempted from obtaining patient consent. Study population. The Vascular Access Center at Shaare Zedek Medical Center is a referral center for vascular access surgery receiving patients for construction and maintenance of arteriovenous accesses from all over Israel. In the year 2012, 442 access operations were performed, of which 357 were for new access construction and 65 were surgical revisions of existing accesses. The study included all patients older than 80 years with endstage renal disease who underwent hemodialysis access construction from January 2005 to December 2009, when follow-up also stopped. Preoperative planning and surgery. All patients had preoperative examinations clinically and with color-coded Doppler ultrasound imaging to plan construction of the access in the outpatient clinic by the surgeon performing the operation.7,8 All preoperative and follow-up Doppler ultrasound examinations were performed by one of the two dedicated access surgeons (D.S., I.G.). Forearm veins were examined with a 5-cm blood pressure cuff inflated to 60 mm Hg for at least 3 minutes and after exercising the hand and gently tapping the veins. Forearm autogenous accesses were constructed only if the veins dilated to a minimum of 3 mm on Doppler ultrasound and radial artery diameter was 1.5 mm or more. If these criteria were not met, the access was constructed above the elbow, again in veins that were a minimum of 3 mm in diameter. Basilic vein transposition was preferred to prosthetic access if the basilic vein diameter was at least 4 mm. Prosthetic accesses with tapered 4- to 7-mm stretch expanded polytetrafluoroethylene (Gore-Tex; W. L. Gore and Associates, Flagstaff, Ariz) were constructed only in patients without suitable veins above the elbow (calcified arteries were deemed acceptable as long as the pulse was palpable). In addition to the suitability of the vessels for access construction, the draining veins and feeding arteries were examined for stenosis of >50% in veins and arteries or arterial peak systolic velocity (PSV) ratio of >3 for the narrowed segment. If these were present or suspected on Doppler ultrasound and there were no suitable vessels on the contralateral side, patients were referred for preoperative angioplasty or had endovascular treatment during the access surgery. All anastomotic configurations were end to side. The operations were performed by the same access surgeons under regional anesthetic block, with full heparinization and prophylactic antibiotics in grafts and transpositions, as ambulatory procedures without hospitalization. Postoperative follow-up. All patients entered our routine access surveillance and maintenance program.7,8 Sutures were removed on postoperative days 10 to 14,
Table I. Demographic data for 134 patients having 146 new hemodialysis access operations during the study period (January 1, 2005, to December 31, 2009) Demographic Total patient No. Gender Male Female Hypertension Ischemic heart disease Congestive heart failure Diabetes mellitus Cerebrovascular accident Peripheral vascular disease
No. (%) 134 (100) 88 46 98 60 32 53 6 11
(66) (34) (73) (45) (24) (40) (4) (8)
and patients with grafts were referred to hemodialysis. All patients were examined by Doppler ultrasound 1 month after surgery and then every 3 months, when a complete evaluation was carried out of the inflow arteries supplying the fistula, anastomoses, and outflow of the draining veins. Criteria for endovascular interventions during follow-up. The following criteria were used as indications for angiographic assessment and possible intervention in autogenous accesses: delayed maturation (vein diameter 3:1 or measured flow 50% was considered hemodynamically significant. Patency and survival. Primary patency was the interval from the time of access placement until any intervention designed to maintain or to re-establish patency, access thrombosis, or the time of measurement of patency. Secondary patency was the interval from the time of access placement until access abandonment, thrombosis, or the time of patency measurement including intervening manipulations (surgical or endovascular interventions) designed to re-establish functionality in thrombosed accesses.9 Secondary patency was considered the most important end point because it reflects the total time that the access is in use. Statistical analysis. Findings were recorded in a spreadsheet (Microsoft Office Excel 2003; Microsoft Corporation, Redmond, Wash). Statistical analysis was carried out with Excel and Prism statistical software (Prism v 3.0; GraphPad Software Inc, San Diego, Calif). Kaplan-Meier survival curves were used to estimate access survival. RESULTS In our center from January 2005 to December 2009, 134 patients 80 years of age and older had 146 new arteriovenous accesses constructed (Table I). Twelve patients had
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Table II. Type of hemodialysis access surgery for 134 patients having 146 new hemodialysis access operations during the study period (January 1, 2005, to December 31, 2009) Type of access Native AVF (128 accesses [88%]) RA-CV BrA-CV BrA-TBasV/CV PTFE graft (18 accesses [12%]) BrA-BasV (forearm) BrA-AxV (arm) Total accesses
Number of accesses (% of subgroup)
% of total
30 (23) 91 (71) 7 (5)
21 62 5
16 (89) 2 (11) 146 (100)
11 1 100
AVF, Arteriovenous fistula; BrA-AxV, brachial artery to axillary vein; BrABasV, brachial artery to basilic vein; BrA-CV, brachial artery to cephalic vein; BrA-TBasV/CV, brachial artery to transposed basilic or cephalic vein; PTFE, polytetrafluoroethylene; RA-CV, radial artery to cephalic vein.
two new accesses each. The mean age was 85 6 2.9 years (median, 85 years; range, 80-95 years). Seventy-four patients were aged 80 to 84 years, 52 patients were 85 to 89 years old, and eight patients were 90 years or older. There were only 46 women (35%), and 53 patients (40%) had diabetes mellitus. Most patients had at least one comorbidity. There were 128 new autogenous accesses constructed (Table II). There were 30 (23%) forearm and 91 (71%) upper arm accesses. Seven (5%) of the upper arm autogenous accesses were brachial artery to transposed basilic vein. Only 18 patients (12%) had prosthetic accesses, 16 loop forearm brachial-basilic and two upper arm brachialaxillary accesses. Twenty-six patients had preoperative venography. Four patients had intraoperative angioplasties because of severe venous stenosis. Two patients had postoperative bleeding that required surgical evacuation of hematomas, and none had infection in the immediate postoperative period. Median follow-up was 13.3 months (mean, 17.6 6 14.1 months; range, 0.4-56.3 months). For all 146 accesses, primary patency at 12, 24, and 36 months was 39%, 33%, and 23%, respectively. Secondary patency was 92%, 83%, and 77% (Fig 1). There were 198 therapeutic endovascular interventions in 76 of the accesses during the study period, with an average of 0.9 interventions per patient-year. Steal developed in 11 patients, nine with brachial-cephalic fistulas and one each with radial-cephalic and brachial to transposed basilic vein fistula. Four patients with grade II-IV symptoms were referred for surgical revision because of the steal, three with brachial-cephalic fistula and the patient with basilic vein transposition. All four had successful flow reduction surgery by banding. There were 18 prosthetic accesses, with only nine remaining in follow-up at 12 months, so no meaningful comparisons can be made. There was no statistical difference between autogenous forearm radial-cephalic access and upper arm brachialcephalic access patency (Fig 2). Thirty radial-cephalic forearm autogenous accesses had a primary patency rate of 36% and
Fig 1. Kaplan-Meier analysis of the primary patency (P patency) and secondary patency (S patency) of arteriovenous accesses (fistulas and grafts) in hemodialysis patients older than 80 years. SEM, Standard error of the mean.
32% and secondary patency of 93% and 84% at 12 and 24 months, respectively. The 91 autogenous upper arm brachial-cephalic accesses had a 12-, 24-, and 36-month primary patency of 40%, 36%, and 29% and secondary patency of 92%, 88%, and 79%, respectively. In patients who had brachial-cephalic fistulas, 40 of 91 accesses (44%) had 128 interventions; and in patients with radial-cephalic fistulas, 17 of 30 accesses (57%) had 28 interventions (P ¼ .2013). Primary patency and secondary patency were similar for accesses in diabetic compared with nondiabetic patients (Fig 3). Fifteen patients with fistula had delayed maturation or nonmaturation. Of these, there were 11 upper arm fistulas: nine underwent balloon-assisted maturation, of which seven matured and went on to dialysis with use of the access, and two failed to mature despite the intervention; one died before having any intervention; and one was unsuitable for intervention and received a new access. Four forearm fistulas failed to mature: two had balloon-assisted maturation, but the accesses did not mature; one patient had early failure of a forearm fistula; and one matured after an additional time interval. The relative risk for delayed maturation or nonmaturation of forearm fistulas (13.3%) compared with brachial-cephalic fistula (12.1%) was 1.1030 (95% confidence interval, 0.3973-3.204; P ¼ .8571). Occlusions. Thirteen autogenous accesses were abandoned during the study period. Two were radial-cephalic, nine were brachial-cephalic, one was brachial-axillary, and one was a brachial to transposed basilic vein access. Two patients refused new access construction and continued hemodialysis through central catheters; one patient died before a central catheter could be inserted. The others had successful construction of a new access, seven autogenous accesses and three grafts. One graft in the study occluded at 1.7 months, and this patient received an autogenous fistula in his dominant arm.
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Fig 2. Kaplan-Meier analysis of the (a) primary patency and (b) secondary patency of brachial-cephalic fistulas vs radial-cephalic fistulas. AVF, Arteriovenous fistula; BrA-CV, brachial artery to cephalic vein; RA-CV, radial artery to cephalic vein; SEM, standard error of the mean.
Patient survival. Kaplan-Meier analysis showed a median patient survival of 38 months after access construction. Forty-nine patients died during the study period. Median survival of those patients who died was 10.7 months (mean, 15.6 6 13.1 months). DISCUSSION In this study, most patients aged 80 years and older were found to have vasculature that was suitable for autogenous access construction, with only 12% prosthetic accesses. There were no significant differences in patency between forearm and upper arm autogenous accesses or between patients with and without diabetes mellitus. Secondary patency was high in autogenous accesses, relying on surveillance and interventions for maintenance of patency.
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Fig 3. Kaplan-Meier analysis of the (a) primary patency and (b) secondary patency of accesses in patients with diabetes mellitus (DM) vs nondiabetic patients. SEM, Standard error of the mean.
In the United States, there has been a steady rise in the number of adult dialysis patients with end-stage renal failure. Since 2000, the prevalence among those aged 75 years and older has grown 44%, whereas the growth in prevalence of those aged 20 to 44 years and 45 to 64 years, in contrast, has been 14% and 19%, respectively.10 In Israel, the mean age of patients requiring renal replacement therapy grew from 56 years in 1990 to 66 years in 2010. Whereas the number of new patients on dialysis rose by 66%, the number of new patients aged 75 years and older rose by 191% in the same period and has been the largest age group receiving renal replacement therapy since 2000. This trend has been accompanied by a constant increase in the proportion of patients on hemodialysis compared with peritoneal dialysis (73% hemodialysis
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patients in 1990 and 90% hemodialysis and 10% peritoneal dialysis in 2007).11 Not surprisingly, mortality rates in the prevalent end-stage renal disease population aged 65 years and older rise by age.10 Although central vein catheters are favored by some authors for the elderly population,12 and more accesses fail to mature in older patients,13 others have suggested that age should not be a limiting factor for arteriovenous access construction.14 It has also been shown that mortality is higher in patients with central venous catheters for hemodialysis than in those with arteriovenous fistula or graft.15,16 The 2006 update of the Kidney Disease Outcomes Quality Initiative recommendations does not distinguish between younger and older patients.17 However, it remains unclear whether constructing fistulas in the elderly will improve long-term patient survival or reduce morbidity. There is evidence that increasing the rate of fistula construction may lead to a higher failure rate13 but also that proper planning for surgery may counter this effect.18 In the present study using preoperative planning, 88% of accesses constructed were autogenous, with 24-month secondary patency of 84% for radial-cephalic (forearm) accesses and 88% for brachial-cephalic (upper arm) accesses. Elderly patients exhibit problems that may compromise the success of dialysis access surgery, such as arteriosclerosis, poor-quality veins, thin skin, and comorbidities.19 One study of the factors associated with early failure of dialysis access demonstrated a higher early failure rate in the age group older than 80 years; the average time to first failure was 230 days overall and 178 days in patients older than 80 years.13 Other studies have not demonstrated an association between age-related risk factors and surgical success or patency.20-23 There is, therefore, no definite conclusion that can be reached about the effect of age on the rate of fistula patency. Our study demonstrates that advanced age is not a reason to avoid fistula construction. The average time to first failure was 219 days for our patients older than 80 years. This improved result may be due to our preoperative planning and aggressive approach to monitoring and maintenance, all carried out by the same access surgeon who performed the surgery.7,8 Whereas 1-year secondary patency in this study of elderly patients was 91.7%, our overall 1-year secondary patency in 220 patients of all ages with fistulas in 2010 was 92%, suggesting that there is no difference in patency rates between the elderly population compared with our dialysis access surgery population. The time to maturation for radial-cephalic fistulas is generally thought to be longer than for brachial-cephalic fistulas, and brachial-cephalic fistulas are also believed to have a higher surgical success rate and lower early failure rate in patients aged 65 years and older.24,25 With this and their limited life expectancy in mind, elderly candidates for hemodialysis may be offered brachial-cephalic fistulas to minimize delays and to maximize dialysis time with that fistula. On the other hand, there is a higher incidence of steal after proximal access procedures in older patients,26 and additional studies have shown that age does not influence
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fistula survival.27,28 In our patients, the difference in primary patency and secondary patency between radialcephalic and brachial-cephalic fistulas did not reach significance, and four patients required surgical revision for steal, all upper arm fistulas. Eighteen polytetrafluoroethylene grafts were created in elderly patients during the study period, only 12% of the accesses created. In a systematic review of 34 studies by Huber et al, both primary patency and secondary patency were better for fistula than for graft.29 In our study, the difference was not significant, but the number of grafts was small. Primary patency has been shown to be decreased in diabetic patients, but secondary patency is the same as for nondiabetics if fistula complications are treated adequately.30 Others have shown that diabetes mellitus has no detrimental effect on outcome after creation of autogenous elbow fistulas for hemodialysis.31 Our study did not demonstrate any difference in primary or secondary patency between diabetic patients and nondiabetics, indicating that there is no justification for regarding diabetes as a risk factor for fistula creation in octogenarians. Maturation rates of more than 50% can be expected for fistula construction with an imaging protocol,17 but surveillance and aggressive follow-up with early endovascular intervention can yield high salvage rates in fistulas that fail to mature.32 A meta-analysis by Rooijens et al that included eight prospective and 30 retrospective studies found a primary failure rate of 15.3% for arteriovenous fistula (range, 6%-34%) with primary and secondary patency of 63% and 66%, respectively.33 Subgroup analysis did not reveal significant differences for age. In the current study, only seven of 128 patients (5.5%) with native fistula had early failure. In hemodialysis patients 65 years and older, there is a significant increase in complication rate and mortality associated with catheter use compared with both fistula and graft.34,35 Patients with permanent central venous catheters for hemodialysis are treated by nephrologists who think that there are medical conditions present precluding arteriovenous access construction. These patients are therefore not referred to our center and were not included in the study. The risk of death is up to 50% higher in patients using central venous catheters compared with those using arteriovenous fistulas or grafts.34,35 The mortality rate in our patients aged 80 years and older with fistula was 21.3% in the first year, compared with a 1-year crude death rate of 24.9% in the study of Medicare patients receiving hemodialysis who were 67 years and older carried out by Xue et al.35 This study has some limitations. This is a single-center study, and although we are a large referral center, our results may not be generalizable to other centers. We do not know how many elderly patients were not referred and were dialyzed with central catheters; however, this would also apply to younger patients who may be thought unsuitable for access construction by the referring nephrologist. In addition, we do not have records of the patients
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who were found to be unsuitable for access construction on the basis of their inability to lie supine or unsuitability of vessels for access construction. There was also a preponderance of men in our study patients (66%) (Table I), which could favor improved outcomes for access surgery. CONCLUSIONS Higher mortality rates in hemodialysis patients with central vein catheters support the use of arteriovenous access for elderly hemodialysis patients to reduce mortality as well as to improve quality of life. Some authors have recently advocated the use of grafts rather than fistulas in the age group older than 80 years.5,6,16,36 However, 88% of patients in this study were found to have vasculature that was suitable for autogenous access construction, with patency and complication rates similar to those of their younger counterparts when adequate preoperative planning and postoperative maintenance were carried out. These patients should not be disqualified from access surgery solely on account of their age. On the contrary, access surgery should be encouraged as there may be no age limit for this procedure. Our findings support the use of radialcephalic fistula as the initial approach in elderly patients if appropriate vessels are available and when adequate preoperative planning and postoperative maintenance are carried out. This should result in fewer complications without compromising patency while allowing maximal use of available vessels. AUTHOR CONTRIBUTIONS Conception and design: OO, DS, JH Analysis and interpretation: OO, DS, JH, IG Data collection: JH, DS, IG Writing the article: JH, DS, OO Critical revision of the article: OO, JH, IG, DS Final approval of the article: OO, JH, IG, DS Statistical analysis: DS, JH, OO Obtained funding: Not applicable Overall responsibility: DS REFERENCES 1. Schmidt RJ. Informing our elders about dialysis: is an age-attuned approach warranted? Clin J Am Soc Nephrol 2012;7:185-91. 2. Bessias N, Paraskevas KI, Tziviskou E, Andrikopoulos V. Vascular access in elderly patients with end-stage renal disease. Int Urol Nephrol 2008;40:1133-42. 3. Vachharajani TJ, Moossavi S, Jordan JR, Vachharajani V, Freedman BI, Burkart JM. Re-evaluating the Fistula First Initiative in Octogenarians on Hemodialysis. Clin J Am Soc Nephrol 2011;6:1663-7. 4. Borzumati M, Funaro L, Mancini E, Resentini V, Baroni A. Survival and complications of arteriovenous fistula dialysis access in an elderly population. J Vasc Access 2013;14:330-4. 5. Vachharajani TJ, Moist LM, Glickman MH, Vazquez MA, Polkinghorne KR, Lok CE, et al. Elderly patients with CKDd dilemmas in dialysis therapy and vascular access. Nat Rev Nephrol 2014;10:116-22. 6. Lok CE, Allon M, Moist L, Oliver MJ, Shah H, Zimmerman D. Risk equation determining unsuccessful cannulation events and failure to maturation in arteriovenous fistulas (REDUCE FTM I). J Am Soc Nephrol 2006;17:3204-12.
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7. Shemesh D, Zigelman C, Olsha O, Alberton J, Shapira J, Abramowitz H. Primary forearm arteriovenous fistula for hemodialysis accessdan integrated approach to improve outcomes. Cardiovasc Surg 2003;11:35-41. 8. Shemesh D, Olsha O, Berelowitz D, Zaghal I, Zigelman CZ, Abramowitz HB. Integrated approach to construction and maintenance of prosthetic arteriovenous access for hemodialysis. Vascular 2004;12:243-55. 9. Sidawy AN, Gray R, Besarab A, Henry M, Ascher E, Silva M Jr, et al. Recommended standards for reports dealing with arteriovenous hemodialysis accesses. J Vasc Surg 2002;35:603-10. 10. U.S. Renal Data System. USRDS 2013 annual data report: atlas of chronic kidney disease and end-stage renal disease in the United States. Bethesda, Md: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2013. Available at: http://www.usrds.org/atlas.aspx. Accessed March 21, 2014. 11. Renal replacement therapy in Israel 1990-2010. ICDC Publication No. 350. Jerusalem, Israel: Israel Ministry of Health and the Israel Society for Nephrology and Hypertension; December 2012. Available at: http:// www.health.gov.il/PublicationsFiles/RRTI1990_2010.pdf. Accessed March 21, 2014. 12. Brothers TE, Morgan M, Robison JG, Elliott BM, Baliga P, Cofer JB, et al. Failure of dialysis access: revise or replace? J Surg Res 1996;60:312-6. 13. Patel ST, Hughes J, Mills JL Sr. Failure of arteriovenous fistula maturation: an unintended consequence of exceeding Dialysis Outcome Quality Initiative Guidelines for Hemodialysis Access. J Vasc Surg 2003;38:439-45. 14. Lok CE, Oliver MJ, Su J, Bhola C, Hannigan N, Jassal SV. Arteriovenous fistula outcomes in the era of the elderly dialysis population. Kidney Int 2005;67:2462-9. 15. Perl J, Wald R, McFarlane P, Bargman JM, Vonesh E, Na Y, et al. Hemodialysis vascular access modifies the association between dialysis modality and survival. J Am Soc Nephrol 2011;22:1113-21. 16. DeSilva RN, Patibandla BK, Vin Y, Narra A, Chawla V, Brown RS, et al. Fistula first is not always the best strategy for the elderly. J Am Soc Nephrol 2013;24:1297-304. 17. National Kidney Foundation. KDOQI clinical practice guidelines and clinical practice recommendations for vascular access. Am J Kidney Dis 2006;48(Suppl 1):S176-243. 18. Robbin ML, Chamberlain NE, Lockhart ME, Gallichio MH, Young CJ, Deierhoi MH, et al. Hemodialysis arteriovenous fistula maturity: US evaluation. Radiology 2002;225:59-64. 19. Basile C, Lomonte C, Vernaglione L, Casucci F, Antonelli M, Losurdo N. The relationship between the flow of arteriovenous fistula and cardiac output in haemodialysis patients. Nephrol Dial Transplant 2008;23:282-7. 20. Wolowczyk L, Williams AJ, Donovan KL, Gibbons CP. The snuffbox arteriovenous fistula for vascular access. Eur J Vasc Endovasc Surg 1999;19:70-6. 21. Grapsa EJ, Paraskevopoulos AP, Moutafis SP, Vourliotou AJ, Papadoyannakis NJ, Digenis GE, et al. Complications of vascular access in hemodialysis (HD)eaged vs. adult patients. Geriatr Nephrol Urol 1998;8:21-4. 22. Golledge J, Smith CJ, Emery J, Farrington K, Thompson HH. Outcome of primary radiocephalic fistula for haemodialysis. Br J Surg 1999;86:211-6. 23. Burt CG, Little JA, Mosquera DA. The effect of age on radiocephalic fistula patency. J Vasc Access 2001;2:110-3. 24. Miller PE, Tolwani A, Luscy CP, Deierhoi MH, Bailey R, Redden DT, et al. Predictors of adequacy of arteriovenous fistulas in hemodialysis patients. Kidney Int 1999;56:275-80. 25. Lazarides MK, Georgiadis GS, Antoniou GA, Staramos DN. A metaanalysis of dialysis access outcome in elderly patients. J Vasc Surg 2007;45:420-6. 26. Field M, MacNamara K, Bailey G, Jaipersad A, Morgan RH, Pherwani AD. Primary patency rates of AV fistulas and the effect of patient variables. J Vasc Access 2008;9:45-50. 27. Weale AR, Bevis P, Neary WD, Boyes S, Morgan JD, Lear PA, et al. Radiocephalic and brachiocephalic arteriovenous fistula outcomes in the elderly. J Vasc Surg 2008;47:144-50.
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28. Lazarides MK, Staramos DN, Kopadis G, Maltezos C, Tzilalis VD, Georgiadis GS. Onset of arterial ’steal’ following proximal angioaccess: immediate and delayed types. Nephrol Dial Transplant 2003;18: 2387-90. 29. Huber TS, Carter JW, Carter RL, Seeger JM. Patency of autogenous and polytetrafluoroethylene upper extremity arteriovenous hemodialysis accesses: a systematic review. J Vasc Surg 2003;38:1005-11. 30. Huijbregts HJ, Bots ML, Wittens CH, Schrama YC, Moll FL, Blankstijn PJ. CIMINO study group. Hemodialysis arteriovenous fistula patency revisited: results of a prospective, multicenter initiative. Clin J Am Soc Nephrol 2008;3:714-9. 31. Murphy GJ, Nicholson ML. Autogenous elbow fistulas: the effect of diabetes mellitus on maturation, patency, and complication rates. Eur J Vasc Endovasc Surg 2002;23:452-7. 32. Falk A. Optimizing hemodialysis arteriovenous fistula maturation. J Vasc Access 2011;12:1-3.
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33. Rooijens PP, Tordoir JH, Stijnen T, Burgmans JP, Smet de AA, Yo TI. Radiocephalic wrist arteriovenous fistula for hemodialysis: meta-analysis indicates a high primary failure rate. Eur J Vasc Endovasc Surg 2004;28:583-9. 34. Astor BC, Eustace JA, Powe NR, Klag MJ, Fink NE, Coresh J. CHOICE Study. Type of vascular access and survival among incident hemodialysis patients: the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) Study. J Am Soc Nephrol 2005;16:1449-55. 35. Xue JL, Dahl D, Ebben JP, Collins AJ. The association of initial hemodialysis access type with mortality outcomes in elderly Medicare ESRD patients. Am J Kidney Dis 2003;42:1013-9. 36. Drew DA, Lok CE. Strategies for planning the optimal dialysis access for an individual patient. Curr Opin Nephrol Hypertens 2014;23: 314-20. Submitted Apr 22, 2014; accepted Jul 5, 2014.
Renal replacement therapy has special implications for older patients, who constitute the fastest growing sector of the incident end-stage renal disease population.1 The increased life expectancy of patients with chronic illnesses has resulted in a considerable increase in the number of older patients requiring dialysis. Improvements in dialysis care have also contributed to the increasing numbers of older dialysis patients. Increasing age is related to lower maturation rates, poorer fistula patency, and lower life expectancy of the hemodialysis patient. Older hemodialysis patients are more
From the Department of Surgery and Vascular Access Center, Shaare Zedek Medical Center (affiliated with the Faculty of Health Sciences, Hebrew University). Author conflict of interest: D.S. receives consulting fees from W. L. Gore and Associates and from Bard Peripheral Vascular. Presented at the Vascular Access Society 7th International Congress, May 5-7, 2011, Istanbul, Turkey. Reprint requests: David Shemesh, MD, Vascular Access Center, Department of Surgery, Shaare Zedek Medical Center, PO Box 3235, Jerusalem 91031, Israel (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2014 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2014.07.005
likely than younger individuals to have poor-quality arm veins because of prior medical interventions and to have atheroma or medial calcification affecting their radial or brachial arteries.2 Such patients are more susceptible to symptomatic steal syndrome because of inflow stenosis. Because of the presence of multiple comorbidities in these elderly patients, any disturbance of this delicate equilibrium is likely to lead to serious complications. For these reasons, many octogenarian patients have hemodialysis access through a tunneled cuffed catheter.3 However, one study has shown that patients older than 75 years with autogenous vascular access can have patency that is similar to that of younger patients.4 Notwithstanding current recommendations, there has been a recent trend away from the Fistula First Initiative in the age group older than 80 years,5 with age being one of the four predictive factors used by Lok et al to predict failure to mature in fistulas.6 In our center, the patient’s age has not been a consideration in the decision to construct arteriovenous hemodialysis access, with the oldest patient to have access surgery aged 94 years. We studied patients older than 80 years who had hemodialysis access construction in our center to determine the type of access that was constructed, the success rate of the operations, the maturation rates and the patency of the accesses, and the mortality rates in these older patients. 1
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METHODS Study design. This was a retrospective study of patients in our hemodialysis access registry that is maintained separately from hospital records and includes all patients undergoing hemodialysis access construction, including any subsequent follow-up and intervention. The study was approved by the Ethics Committee of the Shaare Zedek Medical Center and exempted from obtaining patient consent. Study population. The Vascular Access Center at Shaare Zedek Medical Center is a referral center for vascular access surgery receiving patients for construction and maintenance of arteriovenous accesses from all over Israel. In the year 2012, 442 access operations were performed, of which 357 were for new access construction and 65 were surgical revisions of existing accesses. The study included all patients older than 80 years with endstage renal disease who underwent hemodialysis access construction from January 2005 to December 2009, when follow-up also stopped. Preoperative planning and surgery. All patients had preoperative examinations clinically and with color-coded Doppler ultrasound imaging to plan construction of the access in the outpatient clinic by the surgeon performing the operation.7,8 All preoperative and follow-up Doppler ultrasound examinations were performed by one of the two dedicated access surgeons (D.S., I.G.). Forearm veins were examined with a 5-cm blood pressure cuff inflated to 60 mm Hg for at least 3 minutes and after exercising the hand and gently tapping the veins. Forearm autogenous accesses were constructed only if the veins dilated to a minimum of 3 mm on Doppler ultrasound and radial artery diameter was 1.5 mm or more. If these criteria were not met, the access was constructed above the elbow, again in veins that were a minimum of 3 mm in diameter. Basilic vein transposition was preferred to prosthetic access if the basilic vein diameter was at least 4 mm. Prosthetic accesses with tapered 4- to 7-mm stretch expanded polytetrafluoroethylene (Gore-Tex; W. L. Gore and Associates, Flagstaff, Ariz) were constructed only in patients without suitable veins above the elbow (calcified arteries were deemed acceptable as long as the pulse was palpable). In addition to the suitability of the vessels for access construction, the draining veins and feeding arteries were examined for stenosis of >50% in veins and arteries or arterial peak systolic velocity (PSV) ratio of >3 for the narrowed segment. If these were present or suspected on Doppler ultrasound and there were no suitable vessels on the contralateral side, patients were referred for preoperative angioplasty or had endovascular treatment during the access surgery. All anastomotic configurations were end to side. The operations were performed by the same access surgeons under regional anesthetic block, with full heparinization and prophylactic antibiotics in grafts and transpositions, as ambulatory procedures without hospitalization. Postoperative follow-up. All patients entered our routine access surveillance and maintenance program.7,8 Sutures were removed on postoperative days 10 to 14,
Table I. Demographic data for 134 patients having 146 new hemodialysis access operations during the study period (January 1, 2005, to December 31, 2009) Demographic Total patient No. Gender Male Female Hypertension Ischemic heart disease Congestive heart failure Diabetes mellitus Cerebrovascular accident Peripheral vascular disease
No. (%) 134 (100) 88 46 98 60 32 53 6 11
(66) (34) (73) (45) (24) (40) (4) (8)
and patients with grafts were referred to hemodialysis. All patients were examined by Doppler ultrasound 1 month after surgery and then every 3 months, when a complete evaluation was carried out of the inflow arteries supplying the fistula, anastomoses, and outflow of the draining veins. Criteria for endovascular interventions during follow-up. The following criteria were used as indications for angiographic assessment and possible intervention in autogenous accesses: delayed maturation (vein diameter 3:1 or measured flow 50% was considered hemodynamically significant. Patency and survival. Primary patency was the interval from the time of access placement until any intervention designed to maintain or to re-establish patency, access thrombosis, or the time of measurement of patency. Secondary patency was the interval from the time of access placement until access abandonment, thrombosis, or the time of patency measurement including intervening manipulations (surgical or endovascular interventions) designed to re-establish functionality in thrombosed accesses.9 Secondary patency was considered the most important end point because it reflects the total time that the access is in use. Statistical analysis. Findings were recorded in a spreadsheet (Microsoft Office Excel 2003; Microsoft Corporation, Redmond, Wash). Statistical analysis was carried out with Excel and Prism statistical software (Prism v 3.0; GraphPad Software Inc, San Diego, Calif). Kaplan-Meier survival curves were used to estimate access survival. RESULTS In our center from January 2005 to December 2009, 134 patients 80 years of age and older had 146 new arteriovenous accesses constructed (Table I). Twelve patients had
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Table II. Type of hemodialysis access surgery for 134 patients having 146 new hemodialysis access operations during the study period (January 1, 2005, to December 31, 2009) Type of access Native AVF (128 accesses [88%]) RA-CV BrA-CV BrA-TBasV/CV PTFE graft (18 accesses [12%]) BrA-BasV (forearm) BrA-AxV (arm) Total accesses
Number of accesses (% of subgroup)
% of total
30 (23) 91 (71) 7 (5)
21 62 5
16 (89) 2 (11) 146 (100)
11 1 100
AVF, Arteriovenous fistula; BrA-AxV, brachial artery to axillary vein; BrABasV, brachial artery to basilic vein; BrA-CV, brachial artery to cephalic vein; BrA-TBasV/CV, brachial artery to transposed basilic or cephalic vein; PTFE, polytetrafluoroethylene; RA-CV, radial artery to cephalic vein.
two new accesses each. The mean age was 85 6 2.9 years (median, 85 years; range, 80-95 years). Seventy-four patients were aged 80 to 84 years, 52 patients were 85 to 89 years old, and eight patients were 90 years or older. There were only 46 women (35%), and 53 patients (40%) had diabetes mellitus. Most patients had at least one comorbidity. There were 128 new autogenous accesses constructed (Table II). There were 30 (23%) forearm and 91 (71%) upper arm accesses. Seven (5%) of the upper arm autogenous accesses were brachial artery to transposed basilic vein. Only 18 patients (12%) had prosthetic accesses, 16 loop forearm brachial-basilic and two upper arm brachialaxillary accesses. Twenty-six patients had preoperative venography. Four patients had intraoperative angioplasties because of severe venous stenosis. Two patients had postoperative bleeding that required surgical evacuation of hematomas, and none had infection in the immediate postoperative period. Median follow-up was 13.3 months (mean, 17.6 6 14.1 months; range, 0.4-56.3 months). For all 146 accesses, primary patency at 12, 24, and 36 months was 39%, 33%, and 23%, respectively. Secondary patency was 92%, 83%, and 77% (Fig 1). There were 198 therapeutic endovascular interventions in 76 of the accesses during the study period, with an average of 0.9 interventions per patient-year. Steal developed in 11 patients, nine with brachial-cephalic fistulas and one each with radial-cephalic and brachial to transposed basilic vein fistula. Four patients with grade II-IV symptoms were referred for surgical revision because of the steal, three with brachial-cephalic fistula and the patient with basilic vein transposition. All four had successful flow reduction surgery by banding. There were 18 prosthetic accesses, with only nine remaining in follow-up at 12 months, so no meaningful comparisons can be made. There was no statistical difference between autogenous forearm radial-cephalic access and upper arm brachialcephalic access patency (Fig 2). Thirty radial-cephalic forearm autogenous accesses had a primary patency rate of 36% and
Fig 1. Kaplan-Meier analysis of the primary patency (P patency) and secondary patency (S patency) of arteriovenous accesses (fistulas and grafts) in hemodialysis patients older than 80 years. SEM, Standard error of the mean.
32% and secondary patency of 93% and 84% at 12 and 24 months, respectively. The 91 autogenous upper arm brachial-cephalic accesses had a 12-, 24-, and 36-month primary patency of 40%, 36%, and 29% and secondary patency of 92%, 88%, and 79%, respectively. In patients who had brachial-cephalic fistulas, 40 of 91 accesses (44%) had 128 interventions; and in patients with radial-cephalic fistulas, 17 of 30 accesses (57%) had 28 interventions (P ¼ .2013). Primary patency and secondary patency were similar for accesses in diabetic compared with nondiabetic patients (Fig 3). Fifteen patients with fistula had delayed maturation or nonmaturation. Of these, there were 11 upper arm fistulas: nine underwent balloon-assisted maturation, of which seven matured and went on to dialysis with use of the access, and two failed to mature despite the intervention; one died before having any intervention; and one was unsuitable for intervention and received a new access. Four forearm fistulas failed to mature: two had balloon-assisted maturation, but the accesses did not mature; one patient had early failure of a forearm fistula; and one matured after an additional time interval. The relative risk for delayed maturation or nonmaturation of forearm fistulas (13.3%) compared with brachial-cephalic fistula (12.1%) was 1.1030 (95% confidence interval, 0.3973-3.204; P ¼ .8571). Occlusions. Thirteen autogenous accesses were abandoned during the study period. Two were radial-cephalic, nine were brachial-cephalic, one was brachial-axillary, and one was a brachial to transposed basilic vein access. Two patients refused new access construction and continued hemodialysis through central catheters; one patient died before a central catheter could be inserted. The others had successful construction of a new access, seven autogenous accesses and three grafts. One graft in the study occluded at 1.7 months, and this patient received an autogenous fistula in his dominant arm.
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Fig 2. Kaplan-Meier analysis of the (a) primary patency and (b) secondary patency of brachial-cephalic fistulas vs radial-cephalic fistulas. AVF, Arteriovenous fistula; BrA-CV, brachial artery to cephalic vein; RA-CV, radial artery to cephalic vein; SEM, standard error of the mean.
Patient survival. Kaplan-Meier analysis showed a median patient survival of 38 months after access construction. Forty-nine patients died during the study period. Median survival of those patients who died was 10.7 months (mean, 15.6 6 13.1 months). DISCUSSION In this study, most patients aged 80 years and older were found to have vasculature that was suitable for autogenous access construction, with only 12% prosthetic accesses. There were no significant differences in patency between forearm and upper arm autogenous accesses or between patients with and without diabetes mellitus. Secondary patency was high in autogenous accesses, relying on surveillance and interventions for maintenance of patency.
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Fig 3. Kaplan-Meier analysis of the (a) primary patency and (b) secondary patency of accesses in patients with diabetes mellitus (DM) vs nondiabetic patients. SEM, Standard error of the mean.
In the United States, there has been a steady rise in the number of adult dialysis patients with end-stage renal failure. Since 2000, the prevalence among those aged 75 years and older has grown 44%, whereas the growth in prevalence of those aged 20 to 44 years and 45 to 64 years, in contrast, has been 14% and 19%, respectively.10 In Israel, the mean age of patients requiring renal replacement therapy grew from 56 years in 1990 to 66 years in 2010. Whereas the number of new patients on dialysis rose by 66%, the number of new patients aged 75 years and older rose by 191% in the same period and has been the largest age group receiving renal replacement therapy since 2000. This trend has been accompanied by a constant increase in the proportion of patients on hemodialysis compared with peritoneal dialysis (73% hemodialysis
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patients in 1990 and 90% hemodialysis and 10% peritoneal dialysis in 2007).11 Not surprisingly, mortality rates in the prevalent end-stage renal disease population aged 65 years and older rise by age.10 Although central vein catheters are favored by some authors for the elderly population,12 and more accesses fail to mature in older patients,13 others have suggested that age should not be a limiting factor for arteriovenous access construction.14 It has also been shown that mortality is higher in patients with central venous catheters for hemodialysis than in those with arteriovenous fistula or graft.15,16 The 2006 update of the Kidney Disease Outcomes Quality Initiative recommendations does not distinguish between younger and older patients.17 However, it remains unclear whether constructing fistulas in the elderly will improve long-term patient survival or reduce morbidity. There is evidence that increasing the rate of fistula construction may lead to a higher failure rate13 but also that proper planning for surgery may counter this effect.18 In the present study using preoperative planning, 88% of accesses constructed were autogenous, with 24-month secondary patency of 84% for radial-cephalic (forearm) accesses and 88% for brachial-cephalic (upper arm) accesses. Elderly patients exhibit problems that may compromise the success of dialysis access surgery, such as arteriosclerosis, poor-quality veins, thin skin, and comorbidities.19 One study of the factors associated with early failure of dialysis access demonstrated a higher early failure rate in the age group older than 80 years; the average time to first failure was 230 days overall and 178 days in patients older than 80 years.13 Other studies have not demonstrated an association between age-related risk factors and surgical success or patency.20-23 There is, therefore, no definite conclusion that can be reached about the effect of age on the rate of fistula patency. Our study demonstrates that advanced age is not a reason to avoid fistula construction. The average time to first failure was 219 days for our patients older than 80 years. This improved result may be due to our preoperative planning and aggressive approach to monitoring and maintenance, all carried out by the same access surgeon who performed the surgery.7,8 Whereas 1-year secondary patency in this study of elderly patients was 91.7%, our overall 1-year secondary patency in 220 patients of all ages with fistulas in 2010 was 92%, suggesting that there is no difference in patency rates between the elderly population compared with our dialysis access surgery population. The time to maturation for radial-cephalic fistulas is generally thought to be longer than for brachial-cephalic fistulas, and brachial-cephalic fistulas are also believed to have a higher surgical success rate and lower early failure rate in patients aged 65 years and older.24,25 With this and their limited life expectancy in mind, elderly candidates for hemodialysis may be offered brachial-cephalic fistulas to minimize delays and to maximize dialysis time with that fistula. On the other hand, there is a higher incidence of steal after proximal access procedures in older patients,26 and additional studies have shown that age does not influence
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fistula survival.27,28 In our patients, the difference in primary patency and secondary patency between radialcephalic and brachial-cephalic fistulas did not reach significance, and four patients required surgical revision for steal, all upper arm fistulas. Eighteen polytetrafluoroethylene grafts were created in elderly patients during the study period, only 12% of the accesses created. In a systematic review of 34 studies by Huber et al, both primary patency and secondary patency were better for fistula than for graft.29 In our study, the difference was not significant, but the number of grafts was small. Primary patency has been shown to be decreased in diabetic patients, but secondary patency is the same as for nondiabetics if fistula complications are treated adequately.30 Others have shown that diabetes mellitus has no detrimental effect on outcome after creation of autogenous elbow fistulas for hemodialysis.31 Our study did not demonstrate any difference in primary or secondary patency between diabetic patients and nondiabetics, indicating that there is no justification for regarding diabetes as a risk factor for fistula creation in octogenarians. Maturation rates of more than 50% can be expected for fistula construction with an imaging protocol,17 but surveillance and aggressive follow-up with early endovascular intervention can yield high salvage rates in fistulas that fail to mature.32 A meta-analysis by Rooijens et al that included eight prospective and 30 retrospective studies found a primary failure rate of 15.3% for arteriovenous fistula (range, 6%-34%) with primary and secondary patency of 63% and 66%, respectively.33 Subgroup analysis did not reveal significant differences for age. In the current study, only seven of 128 patients (5.5%) with native fistula had early failure. In hemodialysis patients 65 years and older, there is a significant increase in complication rate and mortality associated with catheter use compared with both fistula and graft.34,35 Patients with permanent central venous catheters for hemodialysis are treated by nephrologists who think that there are medical conditions present precluding arteriovenous access construction. These patients are therefore not referred to our center and were not included in the study. The risk of death is up to 50% higher in patients using central venous catheters compared with those using arteriovenous fistulas or grafts.34,35 The mortality rate in our patients aged 80 years and older with fistula was 21.3% in the first year, compared with a 1-year crude death rate of 24.9% in the study of Medicare patients receiving hemodialysis who were 67 years and older carried out by Xue et al.35 This study has some limitations. This is a single-center study, and although we are a large referral center, our results may not be generalizable to other centers. We do not know how many elderly patients were not referred and were dialyzed with central catheters; however, this would also apply to younger patients who may be thought unsuitable for access construction by the referring nephrologist. In addition, we do not have records of the patients
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who were found to be unsuitable for access construction on the basis of their inability to lie supine or unsuitability of vessels for access construction. There was also a preponderance of men in our study patients (66%) (Table I), which could favor improved outcomes for access surgery. CONCLUSIONS Higher mortality rates in hemodialysis patients with central vein catheters support the use of arteriovenous access for elderly hemodialysis patients to reduce mortality as well as to improve quality of life. Some authors have recently advocated the use of grafts rather than fistulas in the age group older than 80 years.5,6,16,36 However, 88% of patients in this study were found to have vasculature that was suitable for autogenous access construction, with patency and complication rates similar to those of their younger counterparts when adequate preoperative planning and postoperative maintenance were carried out. These patients should not be disqualified from access surgery solely on account of their age. On the contrary, access surgery should be encouraged as there may be no age limit for this procedure. Our findings support the use of radialcephalic fistula as the initial approach in elderly patients if appropriate vessels are available and when adequate preoperative planning and postoperative maintenance are carried out. This should result in fewer complications without compromising patency while allowing maximal use of available vessels. AUTHOR CONTRIBUTIONS Conception and design: OO, DS, JH Analysis and interpretation: OO, DS, JH, IG Data collection: JH, DS, IG Writing the article: JH, DS, OO Critical revision of the article: OO, JH, IG, DS Final approval of the article: OO, JH, IG, DS Statistical analysis: DS, JH, OO Obtained funding: Not applicable Overall responsibility: DS REFERENCES 1. Schmidt RJ. Informing our elders about dialysis: is an age-attuned approach warranted? Clin J Am Soc Nephrol 2012;7:185-91. 2. Bessias N, Paraskevas KI, Tziviskou E, Andrikopoulos V. Vascular access in elderly patients with end-stage renal disease. Int Urol Nephrol 2008;40:1133-42. 3. Vachharajani TJ, Moossavi S, Jordan JR, Vachharajani V, Freedman BI, Burkart JM. Re-evaluating the Fistula First Initiative in Octogenarians on Hemodialysis. Clin J Am Soc Nephrol 2011;6:1663-7. 4. Borzumati M, Funaro L, Mancini E, Resentini V, Baroni A. Survival and complications of arteriovenous fistula dialysis access in an elderly population. J Vasc Access 2013;14:330-4. 5. Vachharajani TJ, Moist LM, Glickman MH, Vazquez MA, Polkinghorne KR, Lok CE, et al. Elderly patients with CKDd dilemmas in dialysis therapy and vascular access. Nat Rev Nephrol 2014;10:116-22. 6. Lok CE, Allon M, Moist L, Oliver MJ, Shah H, Zimmerman D. Risk equation determining unsuccessful cannulation events and failure to maturation in arteriovenous fistulas (REDUCE FTM I). J Am Soc Nephrol 2006;17:3204-12.
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7. Shemesh D, Zigelman C, Olsha O, Alberton J, Shapira J, Abramowitz H. Primary forearm arteriovenous fistula for hemodialysis accessdan integrated approach to improve outcomes. Cardiovasc Surg 2003;11:35-41. 8. Shemesh D, Olsha O, Berelowitz D, Zaghal I, Zigelman CZ, Abramowitz HB. Integrated approach to construction and maintenance of prosthetic arteriovenous access for hemodialysis. Vascular 2004;12:243-55. 9. Sidawy AN, Gray R, Besarab A, Henry M, Ascher E, Silva M Jr, et al. Recommended standards for reports dealing with arteriovenous hemodialysis accesses. J Vasc Surg 2002;35:603-10. 10. U.S. Renal Data System. USRDS 2013 annual data report: atlas of chronic kidney disease and end-stage renal disease in the United States. Bethesda, Md: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2013. Available at: http://www.usrds.org/atlas.aspx. Accessed March 21, 2014. 11. Renal replacement therapy in Israel 1990-2010. ICDC Publication No. 350. Jerusalem, Israel: Israel Ministry of Health and the Israel Society for Nephrology and Hypertension; December 2012. Available at: http:// www.health.gov.il/PublicationsFiles/RRTI1990_2010.pdf. Accessed March 21, 2014. 12. Brothers TE, Morgan M, Robison JG, Elliott BM, Baliga P, Cofer JB, et al. Failure of dialysis access: revise or replace? J Surg Res 1996;60:312-6. 13. Patel ST, Hughes J, Mills JL Sr. Failure of arteriovenous fistula maturation: an unintended consequence of exceeding Dialysis Outcome Quality Initiative Guidelines for Hemodialysis Access. J Vasc Surg 2003;38:439-45. 14. Lok CE, Oliver MJ, Su J, Bhola C, Hannigan N, Jassal SV. Arteriovenous fistula outcomes in the era of the elderly dialysis population. Kidney Int 2005;67:2462-9. 15. Perl J, Wald R, McFarlane P, Bargman JM, Vonesh E, Na Y, et al. Hemodialysis vascular access modifies the association between dialysis modality and survival. J Am Soc Nephrol 2011;22:1113-21. 16. DeSilva RN, Patibandla BK, Vin Y, Narra A, Chawla V, Brown RS, et al. Fistula first is not always the best strategy for the elderly. J Am Soc Nephrol 2013;24:1297-304. 17. National Kidney Foundation. KDOQI clinical practice guidelines and clinical practice recommendations for vascular access. Am J Kidney Dis 2006;48(Suppl 1):S176-243. 18. Robbin ML, Chamberlain NE, Lockhart ME, Gallichio MH, Young CJ, Deierhoi MH, et al. Hemodialysis arteriovenous fistula maturity: US evaluation. Radiology 2002;225:59-64. 19. Basile C, Lomonte C, Vernaglione L, Casucci F, Antonelli M, Losurdo N. The relationship between the flow of arteriovenous fistula and cardiac output in haemodialysis patients. Nephrol Dial Transplant 2008;23:282-7. 20. Wolowczyk L, Williams AJ, Donovan KL, Gibbons CP. The snuffbox arteriovenous fistula for vascular access. Eur J Vasc Endovasc Surg 1999;19:70-6. 21. Grapsa EJ, Paraskevopoulos AP, Moutafis SP, Vourliotou AJ, Papadoyannakis NJ, Digenis GE, et al. Complications of vascular access in hemodialysis (HD)eaged vs. adult patients. Geriatr Nephrol Urol 1998;8:21-4. 22. Golledge J, Smith CJ, Emery J, Farrington K, Thompson HH. Outcome of primary radiocephalic fistula for haemodialysis. Br J Surg 1999;86:211-6. 23. Burt CG, Little JA, Mosquera DA. The effect of age on radiocephalic fistula patency. J Vasc Access 2001;2:110-3. 24. Miller PE, Tolwani A, Luscy CP, Deierhoi MH, Bailey R, Redden DT, et al. Predictors of adequacy of arteriovenous fistulas in hemodialysis patients. Kidney Int 1999;56:275-80. 25. Lazarides MK, Georgiadis GS, Antoniou GA, Staramos DN. A metaanalysis of dialysis access outcome in elderly patients. J Vasc Surg 2007;45:420-6. 26. Field M, MacNamara K, Bailey G, Jaipersad A, Morgan RH, Pherwani AD. Primary patency rates of AV fistulas and the effect of patient variables. J Vasc Access 2008;9:45-50. 27. Weale AR, Bevis P, Neary WD, Boyes S, Morgan JD, Lear PA, et al. Radiocephalic and brachiocephalic arteriovenous fistula outcomes in the elderly. J Vasc Surg 2008;47:144-50.
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28. Lazarides MK, Staramos DN, Kopadis G, Maltezos C, Tzilalis VD, Georgiadis GS. Onset of arterial ’steal’ following proximal angioaccess: immediate and delayed types. Nephrol Dial Transplant 2003;18: 2387-90. 29. Huber TS, Carter JW, Carter RL, Seeger JM. Patency of autogenous and polytetrafluoroethylene upper extremity arteriovenous hemodialysis accesses: a systematic review. J Vasc Surg 2003;38:1005-11. 30. Huijbregts HJ, Bots ML, Wittens CH, Schrama YC, Moll FL, Blankstijn PJ. CIMINO study group. Hemodialysis arteriovenous fistula patency revisited: results of a prospective, multicenter initiative. Clin J Am Soc Nephrol 2008;3:714-9. 31. Murphy GJ, Nicholson ML. Autogenous elbow fistulas: the effect of diabetes mellitus on maturation, patency, and complication rates. Eur J Vasc Endovasc Surg 2002;23:452-7. 32. Falk A. Optimizing hemodialysis arteriovenous fistula maturation. J Vasc Access 2011;12:1-3.
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33. Rooijens PP, Tordoir JH, Stijnen T, Burgmans JP, Smet de AA, Yo TI. Radiocephalic wrist arteriovenous fistula for hemodialysis: meta-analysis indicates a high primary failure rate. Eur J Vasc Endovasc Surg 2004;28:583-9. 34. Astor BC, Eustace JA, Powe NR, Klag MJ, Fink NE, Coresh J. CHOICE Study. Type of vascular access and survival among incident hemodialysis patients: the Choices for Healthy Outcomes in Caring for ESRD (CHOICE) Study. J Am Soc Nephrol 2005;16:1449-55. 35. Xue JL, Dahl D, Ebben JP, Collins AJ. The association of initial hemodialysis access type with mortality outcomes in elderly Medicare ESRD patients. Am J Kidney Dis 2003;42:1013-9. 36. Drew DA, Lok CE. Strategies for planning the optimal dialysis access for an individual patient. Curr Opin Nephrol Hypertens 2014;23: 314-20. Submitted Apr 22, 2014; accepted Jul 5, 2014.
