From the Vascular and Endovascular Surgery Society Arteriovenous fistula maturation rate is not affected by ipsilateral tunneled dialysis catheter Jerry J. Kim, MD, Joseph L. Mills, MD, Jonathan Braun, MD, Neal Barshes, MD, MPH, Panos Kougias, MD, and Houssam K. Younes, MD, Houston, Tex ABSTRACT Objective: The effect that ipsilateral tunneled dialysis catheters (TDC) have on arteriovenous fistula (AVF) maturation is unclear. We sought to define this association by comparing AVF maturation rates in patients with contralateral TDC with those with ipsilateral TDC. Methods: A review of a prospectively maintained database including all AVF creation procedures between 2009 and 2016 was performed. All patients with a TDC in place at the time of AVF creation were included in this study. Clinical and functional maturation rates were compared in patients with contralateral vs ipsilateral dialysis catheters. Categorical variables were analyzed by a two-tailed Fisher’s exact test. A P value of less than .05 was considered statistically significant. Results: There were 187 patients who underwent fistula creation with a TDC in place during the study period. Of those, 137 patients had a contralateral TDC and 50 had an ipsilateral TDC. A greater proportion of contralateral patients were first- time dialysis access patients at the time of index AVF creation (67% vs 48%; P ¼ .03). There was no difference in clinical (contralateral 73% vs ipsilateral 78%; P ¼ .57) and functional (contralateral 64% vs ipsilateral 74%) maturation rates between the two groups. The rate of TDC removal after AVF maturation was also not different (contralateral 64% vs ipsilateral 72%; P ¼ .30). There was also no statistical difference in the rates of thrombosis at less than 30 days, outflow stenosis, central stenosis, and steal syndrome. Conclusions: There was no association between TDC sidedness and AVF maturation or early failure in our cohort. Planning for AVF creation should not be influenced by attempts to avoid an ipsilateral TDC. (J Vasc Surg 2019;70:1629-33.) Keywords: Dialysis access; Arteriovenous fistula; Dialysis catheter For patients requiring permanent hemodialysis access, current National Kidney Foundation/Kidney Disease Out- comes Quality Initiative guidelines advocate for creation of an autogenous arteriovenous fistula (AVF) over arterio- venous graft (AVG). 1 Although exceptions exist with respect to certain patient populations, the AVF is gener- ally associated with fewer complications and higher patency rates as well as lower overall cost, 2-6 However, AVFs require a postoperative maturation period of at least 6 weeks before hemodialysis cannulation, which is a major disadvantage. Further, nonmaturation and pri- mary failure of AVFs require interventions to promote maturation or abandonment of the AVF altogether, which results in an even longer delay to functional hemodialysis access. The period of time required to achieve functional matu- ration of an AVF is of greatest concern in patients already requiring hemodialysis via a tunneled dialysis catheter (TDC). Infection and sepsis associated with TDCs lead to a substantial morbidity and mortality rate. 1,7,8 Thus, the expeditious removal of TDC should be of primary impor- tance in this end-stage renal disease population. When planning AVF creation in a patient with pre- existing TDC, surgeons may intuitively avoid the arm ipsilateral to the TDC. Unfortunately, this strategy limits the number of AVF creation sites by one-half and may lead to AVF creation in a dominant arm or an arm with a less favorable venous anatomy. Indeed, concerns regarding ipsilateral TDC-associated central venous stenosis or increased outflow resistance in this setting is understandable. However, there are few data regarding the effect that an ipsilateral TDC has on AVF maturation rates. We sought to define this association by comparing AVF maturation rates in patients with contralateral TDC with those with ipsilateral TDC. METHODS This study was approved by the institutional review board as well as the research and development commit- tee at the Michael E. DeBakey Veterans Affairs Medical From the Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine. Author conflict of interest: none. Presented at the Vascular and Endovascular Surgery Society Annual Meeting, Boston, Mass, June 20, 2018. Correspondence: Jerry J. Kim, MD, Division of Vascular Surgery, Baylor College of Medicine, One Baylor Plaza, MS 390, Houston, TX 77030 (e-mail: jerryk@bcm. edu). 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 2019 by the Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jvs.2019.01.084 1629
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