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Impact of Tunneled Dialysis Catheters on First Time Arteriovenous Fistulas: Is Vascular Surgery Consulted too Late?

Objective:
With the Kidney Disease Outcomes and Quality Initiative (KDOQI) guidelines in mind, the utilization of tunneled dialysis catheters (TDC) in first time arteriovenous fistulas (AVF) was reviewed.
Methods:
A retrospective review of all consecutive patients undergoing new, first time access procedures from January 2005 through December 2005 was performed. Standard statistical methods and Kaplan-Meier curves were used to analyze the data.
Results:
During the study period, arteriovenous fistula was performed as the first attempt at permanent access in 168 patients. We had 104 (62%) males, 105 (63%) African Americans, 88 (52%) diabetics, and 155 (92%) patients with hypertension. One hundred twenty nine patients (77%) required peri-operative TDC placement (75 before, 35 at the same time, and 23 after but prior to AVF cannulation). Patients without a TDC had a yearly intervention rate (YIR) of 0.34 interventions/patient/year. Those who had one or more catheters had YIR of 1.29 to help maturation or maintain a functional access (p=0.003). The primary patency of AVF in patients who did not have a TDC was 47% compared to 16% in those with catheters (p=0.01). There was no significant difference in the secondary patency. However, there was a trend that if the TDC was placed before the creation of the AVF secondary patency was worse (p=0.19). In the 75 patients in whom TDC were placed prior to AVF creation, there was an average of 85.5 catheter days.
Conclusion:
Tunneled dialysis catheter placement prior to AVF creation significantly decreases primary patency and increases the yearly intervention rate. Unfortunately, a majority of patients are referred at or after initiation of hemodialysis. This late referral pattern has a detrimental impact on access performance.