Surgical revision to salvage degeneration of hemodialysis access is effective but is associated with a high burden of reinterventions

Abstract

Background:

Aneurysmal degeneration and ulceration of arteriovenous access (AV-access) for hemodialysis is a morbid and potentially lethal scenario. Outcomes of surgical revision to salvage failing AV-access versus ligation followed by new access creation are not well described. We hypothesized that surgical revision would be associated with reduced tunneled dialysis catheter use but increased reinterventions.

Methods:

This single center retrospective study included all adult patients with aneurysmal, ulcerated, or bleeding AV-accesses undergoing surgical revision or ligation (2020–2023). Univariate statistics and Kaplan-Meier analysis compared characteristics and outcomes across groups. The decision to salvage versus ligate AV-access was based on the clinical judgment of the treating surgeon.

Results:

The cohort of 89 patients had a median age of 61 years and expected high rates of comorbidities which were not different between groups, including diabetes (45%), coronary artery disease (40%), and heart failure (37%). Of the 89 patients included, 15 had AV grafts and 74 had AV fistulas. The indications for intervention included aneurysmal degeneration alone (n = 39), ulceration (n = 24), and ulceration with bleeding (n = 26). Underlying aneurysmal degeneration was present in 72% of patients with ulceration and bleeding. Surgical revision to salvage AV-access was associated with reduced dialysis catheter use compared to ligation—44% after revision compared to 81% after ligation (p < 0.01) and fewer overall postoperative days with a dialysis catheter after surgery (p < 0.02). Reinterventions were more common after open revision versus ligation (58% vs 32%, p = 0.03), but only 5 patients (10%) in the open revision group required placement of a new surgical access during the follow up period.

Conclusions:

Despite a high rate of reinterventions, patients who underwent an open revision to salvage their av-access had significantly reduced dialysis catheter utilization and few required new surgical access creations. AV-access salvage should be considered for failing AV-access whenever possible to mitigate dialysis catheter-associated complications.