FP643PREDICTORS AND OUTCOMES IN SECONDARY PATENCY OF ARTERIOVENOUS GRAFTS FOR HEMODIALYSIS

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INTRODUCTION: Arteriovenous prosthetic graft (AVG) is an effective alternative hemodialysis (HD) vascular access (VA) choice. Its performance is limited due to a high incidence of failure attributed to neomyointimal hyperplasia, leading to thrombosis. Our objective was to analyze outcomes in terms of cumulative secondary survival (CSS) and secondary patency rate (SPR) of AVG and to determine prognostic factors for these outcomes. METHODS: It was a retrospective, single center cohort analysis. Incident HD patients that received implantation of an AVG for angioaccess from January 2015 to December 2018 were included. All patients were assigned to an intensified surveillance protocol with monthly Color Doppler ultrasound (CDUS) and referred to for corrective or access salvation surgical or endovascular procedures when required. Demographic factors, timing, type and site of implanted AVG, as well as types of treatment of VA malfunction or failure were all recorded and analysed. Outcomes included CSS (time from implantation to abandon) and SPR in 12, 24, 36 and 48 months. Kaplan-Meier survival analysis was conducted; univariate and multivariate analyses were used to evaluate prognostic factors. RESULTS: Data from 223 patients (113 male, 110 female), aged 62±12, in HD for 123±148 months were analysed. These involved 119 proximal (arm) AVG, 101 loop (forearm) AVG and 1 leg AVG, of which 147 were ePTFE grafts, 39 acute cannulation AVGs and 37 biological vascular conduits. During the follow-up period (mean duration 25±38 months) CSS was 49±4 months and SPR were 74%, 63%, 52%, 43% in 12, 24, 36 and 48 months, respectively. Multivariate analysis demonstrated that secondary patency was not associated with age at intervention, gender, duration in HD, graft position, stent deployment or use of cutting balloon for pre-emptive stenotic lesion corrections. Patency was negatively affected by the type of implanted graft (reference- ePTFE; acute cannulation-HR, 3.09; 95%CI,1.66-5.75;p <0.005, biological–HR, 0.70; 95% CI, 0.39-1.24;p=0.218), presence and number of successfully treated thrombotic events in access history, with differences noted depending on the type of treatment selected (reference-no history of thrombosis; Fogarty thrombectomy - HR, 3.63; 95% CI, 1.89-6.98; p <0.005, Trerotola percutaneous thrombolysis–HR,3.14;95%CI,1.53-6.43;p=0.002, bothtechniques-HR,3.62;95%CI1.92-6.84;p<0.005). Apositive correlation was demonstrated between increasing number of successful pre-emptive percutaneous angioplasties (PTA) and VA secondary patency (HR,0.90; 95% CI, 0.83-0.98; p=0.019). period. Interestingly, after an average of 4.2±4.5 pre-emptive PTAs per access performed during the study period, the association of CSS and stenosis proved to be weak (reference- no stenosis; stenosis - HR, 0.74; 95% CI, 0.32-1.70; p=0.474), a finding that requires further analyses. CONCLUSIONS: Factors such as age, site or time on dialysis, traditionally thought to adversely affect access prognosis may not influence secondary outcomes of AVG. Use of new technology conduits, stenting or sophisticated, expensive endovascular catheters and declogging techniques may not contribute in prolonging survival of HD accesses. However, it was demonstrated that an intensified surveillance CDUS protocol permitting prompt stenosis recognition and pre-emptive correction could be a milestone in our continuous challenge for improving patency.

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