For Old or Young Dialysis Patients,
AV Fistulas Remain Pure Gold
Andrew R. Forauer, MD
Michael Bazylewicz, BS
Kristine A. Pattin, BS
Interventional Radiology
Dartmouth-Hitchcock Medical Center
Lebanon, NH
Scope of the problem
• End-stage kidney disease effects hundreds of
thousands of U.S. patients
• Approximately 400,000 require hemodialysis
• 20 % of those on dialysis are age 75 or older
• That’s 1 out of 5 patients !
When your kidneys don’t work
• Kidneys filter the blood & remove harmful
substances
• When they don’t work properly, the toxins
accumulate, & patients become ill
• They will require :
– an artificial form of blood filtering (=DIALYSIS)
– kidney transplant
Dialysis 101
• This requires
removing blood,
filtering it, and
returning it the patient
Dialysis 101
• This filtering can be accomplished by creating a
connection between an artery & a vein, typically in the
arm.
• Termed an ARTERIOVENOUS (AV) access
• The preferred method uses the patient’s own veins to
create this connection (=an AV fistula)
Left upper arm AV fistula
Fistula (vein)
artery
The flow of blood is indicated
by the arrows () from the
artery, into the fistula & back to
the heart.
Connection of the
vein to the artery
• Unfortunately, narrowings develop in these AV
fistulas over time
• Reducing blood flow through them
• Making dialysis less efficient
• Requires a medical procedure to correct
• Interventional Radiologists can identify these
narrowings, position a balloon catheter , & dilate
them (Angioplasty)
Misconception: The elderly patient does not do
well when they require dialysis
• Why wouldn’t the way we provide dialysis be the
same for younger vs. older patients?
• The elderly may have more chronic medical
conditions & be receiving more medications
• But do these factors effect the patient’s AV
access ?
Goals
• Does balloon dilation (angioplasty) of dialysis
fistulas in elderly patients work the same, better, or
worse compared to younger patients ?
• Are the patency rates (how long these fistulas
remained open) in older patients to a younger patients
the same ?
Comparing the two groups
Number of patients
Average age
(years)
Time on dialysis
(days)
Patients aged 75 yrs &
older
Younger patients
(age 40 – 60 yrs)
38
36
80.0
52.9
120
360
Co-existing medical conditions
Patients aged 75
yrs & older
Younger patients
(age 40 – 60 yrs)
Diabetes
17
24
High blood
pressure
30
27
Heart disease or
atherosclerosis
28
15
52%
63%
Heart function
(% EF)
Our Findings…
• Heart or vascular disease, the time spent on
dialysis & medications had no influence on two
important aspects:
1. how long the access stayed open
2. response to angioplasty to keep them open
How well did angioplasty work in
keeping the access open ?
• Older patients (75 years &
older):
– 200.2 days (6.7 months)
• Patients age 40 – 60 years:
– 211.5 days (7 months)
• No significant difference
Summary
• Our results support:
– creating AV fistulas for dialysis in older patients;
this is the preferred route for treatment
– the key role Interventional Radiology plays in
keeping them open and functioning properly
• Older patient age alone should not be viewed as
limiting the patient’s access options