Thread by @aishaikh

💥Tweetorial on ‘Are AVF’s the best dialysis vascular access?
⚡️Do AVFs have better long term patency than AVGs?
⚡️Impact of vascular access type on clinical outcomes?
⚡️Are AVFs cost effective in all pts?
@RenalFellowNtwk
#VascularAccessPearls

💥Do AVF’s have better long term patency than AVGs?
⚡️Observational studies have shown that AVFs have better cumulative access survival than AVGs but...👇🏽

💥Why is it important to look at the cumulative AV access survival from the ‘Time of AV access creation’ and NOT from the ‘Time of successful AV access use’?
⚡️Let’s take a look at this study which compared the cumulative survival of AVF vs. AVG 👇🏽

💥Study results: Primary failure rate was significantly ⬆️ for AVF than for AVG
⚡️If primary failures were included in the analysis then there was NO difference in total access survival of AVF & AVG
⚡️But if primary failures were excluded then 👇🏽

💥This is not an isolated finding. Other studies have shown similar results 👇🏽
⚡️AVF and AVG survival is similar if primary failures are included in the analysis 👇🏽

💥So do AVFs have better long term patency than AVGs?
⚡️A functioning AVF has a better cumulative access survival & requires fewer interventions to maintain patency compared to an AVG
⚡️But primary failure rate for AVF is significantly higher than AVG 👇🏽

💥What is the impact of vascular access type on clinical outcomes?
⚡️Obervational studies have shown that pts. w/ AVF have better survival, lower risk of infection & CV disease than pts. with AVG and CVC - but there is no data available from RCTs

💥In the absence of RCT data, perhaps the better approach would be to:
⚡️Assess clinical outcomes based on ‘Vascular access first placed’ and NOT the ‘Vascular access first used’
⚡️This study did just that 👇🏽

💥The study found that the pts. who had an AVF placed but initiated HD w/ a CVC had a 64%-74% ⬇️ mortality than pts. who initiated HD with a CVC and did not have an AVF placed 👇🏽

💥 So what is the impact of vascular access type on clinical outcomes?
⚡️Pts. with AVF have better survival compared to pts. w/ CVCs, but survival benefit is NOT entirely explained by the vascular access type alone, & pt. factors likely play a key role

💥Are AVFs cost effective in ALL patients?
⚡️To answer the question above one has to first answer these 2 fundamental questions:
⚡️What is likelihood of achieving a successful AVF in a patient?
⚡️What is the life expectancy of the patient?

💥What is the likelihood of achieving a successful AVF in a patient?
⚡️One needs to know the risk factors for AVF failure 👇🏽

💥Any decision re: the choice of vascular access creation must take into account:
⚡️pt’s age,co-morbidities and life expectancy
⚡️👀 at this study - it showed that pts. w/ 4 or > co-morbid conditions had a 1-yr survival of <50% after starting dialysis 👇🏽

💥Cost related to vascular access is significantly higher for patients who have primary AVF failure but why?
⚡️Because primary AVF results in CVC-dependence which is associated with ⬆️ cost due to ⬆️ risk of bacteremia/hospitalization 👇🏽

💥So are AVFs cost effective in ALL patients?
⚡️No - but AVFs are cost-effective in pts. who can achieve a functional AVF
⚡️However, it is a challenge to predict AVF success - there are scoring systems to help predict AVF success but they are not perfect 👇🏽

💥Cost effectiveness of AVF in pts. w/ low life expectancy?
👇🏽 Study showed that AVFs are NOT more cost effective than AVGs in pts. w/ life expectancy of < 2 yrs
⚡️Neither AVFs nor AVGs are more cost effective than CVCs when life expectancy is < 6 months 👇🏽

💥Before we get to the summary of the tweetorial it may be worthwhile to see which dialysis vascular access patient’s prefer?
⚡️Catheters!
👀👇🏽

💥Summary
⚡️AVF is NOT the best vascular access for every patient
⚡️Clinicians have to consider pt’s. age, co-morbidities, life expectancy, outcome of prior AV access, QoL, Pt. preference when making vascular access decisions
💥 One size does not fit all💥