Patient Factors Impacting Dialysis Patency: A Tool to Guide Decision Making for Creation of Lower Extremity Arteriovenous Access.

BACKGROUND: Lower extremity access remains a last resort for many patients needing dialysis access. We sought to identify patient factors impacting lower extremity arteriovenous fistula (AVF) and arteriovenous graft (AVG) patency and create a clinical tool to help guide decision-making in these complex patients.

METHODS: All patients in the Vascular Quality Initiative dialysis module undergoing lower extremity access creation from 2011 to 2023 were separated into 2 cohorts based off whether the access was AVF or AVG and retrospectively analyzed. Univariate Kaplan-Meier and multivariable regression analyses were conducted with outcomes being overall survival and primary/secondary patency. Significant factors were standardized and scaled to create scores for loss of secondary patency. The model was then internally validated and imported into a clinical calculator to generate a score that was predictive of loss of patency (the Dialysis Patency Estimation score).

RESULTS: In addition, 1,213 patients underwent creation of lower extremity access from 2011 to 2023 with 151 (12.45%) AVF and 1,062 (87.5%) AVG. One-year primary patency was 52.18% and secondary patency was 77.56% No difference was seen with primary patency based on access type (AVF 60.5%/AVG 50.9%, P = 0.068); however, AVG had worse secondary patency (AVF 88.6%/AVG 74.3%, P = 0.013). Factors increasing loss of secondary patency included: length of stay, age, body mass index, peripheral vascular disease, diabetes, and prior AVF/AVG. These factors were standardized and scaled to create a scoring system of 0 to 100 to predict loss of secondary patency at 1 year, with a score of >56 being near 100% risk. This scoring system was separated into 4 groups to predict risk of loss of patency (0-40 = low risk, 41-50 = medium low risk, 51-55 = medium high risk, and 56-100 = high risk).

CONCLUSION: Lower extremity AVG has inferior patency compared to AVF, but are more commonly placed. We have created a risk stratification score to determine which patients may benefit from a lower extremity AVG.