Lee T et al. (2007) Comparison of survival of upper arm arteriovenous fistulas and grafts after failed forearm fistula. J Am Soc Nephrol 18: 1936–1941

Arteriovenous fistulas are believed to be superior to grafts for vascular access in hemodialysis patients, but it is unclear whether this holds true in patients with a previous fistula failure. A recent study analyzed data from 110 patients who experienced primary failure of an initial forearm fistula and had a subsequent access placed in their upper arm. Preoperative vascular mapping and clinical findings were used to decide whether the subsequent access was a graft (n = 51) or a second fistula (n = 59).

Patients in whom an upper arm fistula was created were significantly more likely to experience primary access failure than were those who received an upper arm graft (44% vs 20%; P = 0.006). Patients who received fistulas required more access interventions before successful cannulation was achieved (0.42/patient vs 0.16/patient; P = 0.04). Among 88 patients already on hemodialysis when they received their upper arm access, those with fistulas were catheter-dependent for longer than those with grafts (131 days vs 34 days; P <0.0001) and suffered more bacterial catheter infections (1.3 episodes vs 0.4 episodes; P = 0.003). Median cumulative access survival was similar in the two groups, but when patients with primary access failure were excluded from the analysis, median cumulative access survival was longer in patients with fistulas (1,524 days vs 517 days; P = 0.03). Following access maturation, fewer interventions were needed to maintain access patency in patients with fistulas than in those with grafts (0.73/year vs 2.38/year; P <0.001).

The authors conclude that trade-offs must be made when deciding which type of access is most suitable for patients who have experienced forearm fistula failure.