Relevance of a skilled vascular surgeon and optimized facility practices in the long-term patency of arteriovenous fistulas: a prospective study

Abstract Introduction: Arteriovenous fistulas (AVF) are the best hemodialysis vascular accesses, but their failure rate remains high. Few studies have addressed the role of the vascular surgeon's skills and the facility's practices. We aimed to study these factors, with the hypothesis that the surgeon's skills and facility practices would have an important role in primary failure and patency rates at 12 months, respectively. Methods: This was a single-center, prospective cohort study carried out from March 2005 to March 2017. Only incident patients were included. A single surgeon made all AVFs, either in the forearm (lower) or the elbow (upper). Vascular access definitions were in accordance with the North American Vascular Access Consortium. Results: We studied 113 AVFs (65% lower) from 106 patients (39% diabetics, 58% started with catheter). Time to first connection was 21.5 days (IR: 14 - 31). Only 14 AVFs (12.4%) underwent primary failure and 18 failed during the first year. Functional primary patency rate was 80.9% (SE 4.1) whereas primary unassisted patency rate, which included PF, was 70.6% (4.4). Logistic regression showed that diabetes (OR = 3.3, 95%CI 1.38 - 7.88, p = .007) and forearm location (OR = 3.03, 95CI% 1.05 - 8.76, p = 0.04) were predictors of AVF failure. Patency of lower and upper AVFs was similar in non-diabetics, while patency in diabetics with lower AVFs was under 50%. (p = 0.003). Conclusions: Results suggest that a long-lasting, suitable AVF is feasible in almost all patients. The surgeon's skills and facility practices can have an important role in the long term outcome of AVF.

摘要 引言：动静脉内瘘（Arteriovenous Fistula, AVF）是血液透析的最佳血管通路，但其失功率仍居高不下。目前鲜有研究探讨血管外科医师操作技能与医疗机构操作规范的作用。本研究旨在探究上述两类因素，提出假设：医师操作技能与医疗机构操作规范分别对动静脉内瘘的原发性失功及12个月通畅率具有重要影响。
方法：本研究为2005年3月至2017年3月开展的单中心前瞻性队列研究，仅纳入新发患者。所有动静脉内瘘均由同一名外科医师完成，手术部位分为前臂（低位）与肘部（高位）。血管通路的定义符合北美血管通路联盟（North American Vascular Access Consortium）的标准。
结果：本研究纳入106例患者的113例动静脉内瘘（65%为低位内瘘），其中39%为糖尿病患者，58%的患者初始透析采用导管通路。首次透析连通时间为21.5天（四分位间距：14~31天）。仅14例（12.4%）动静脉内瘘发生原发性失功，18例在随访第一年内出现失功。功能性初级通畅率为80.9%（标准误SE=4.1）；包含原发性失功在内的无辅助初级通畅率为70.6%（SE=4.4）。Logistic回归分析显示，糖尿病（比值比OR=3.3，95%置信区间CI：1.38~7.88，P=0.007）与内瘘位于前臂（OR=3.03，95%CI：1.05~8.76，P=0.04）是动静脉内瘘失功的预测因素。非糖尿病患者的低位与高位动静脉内瘘通畅率无显著差异，而合并糖尿病且接受低位内瘘手术的患者通畅率低于50%（P=0.003）。
结论：研究结果表明，几乎所有患者均可实现持久且适配的动静脉内瘘。血管外科医师的操作技能与医疗机构的操作规范，对动静脉内瘘的长期预后具有重要作用。