F- 01 : arterio-venous fistula
F- 01 : Catheters
F- 01 : vascular complications
PTFE Grafts Versus Tunneled Cuffed Catheters for Hemodialysis: Which
Is the Second Choice When Arteriovenous Fistula Is Not Feasible?
Gabriele Donati, Giuseppe Cianciolo, Raffaella Mauro, Paola Rucci et al.
Journal : Artificial Organs
Year : 2015 / Month : February
Volume 39
Page : 134–141
DOI: 10.1111/aor.12353
Keywords: Hemodialysis; Grafts; Tunneled cuffed permanent catheters; Complications; Survival
ABSTRACT
Vascular access-related complications are still one of the leading causes of morbidity in
hemodialysis patients. The aim of this study was to compare polytetrafluoroethylene (PTFE) grafts
versus tunneled cuffed permanent catheters (TCCs) in terms of vascular access and patients'
survival. An observational study was carried out with a 2-year follow-up. Eighty-seven chronic
hemodialysis patients were enrolled: 31 with a PTFE graft as vascular access for hemodialysis
versus 56 with a TCC. Patients' mean age was 63.8 ± 14.6 (grafts) versus 73.5 ± 11.3 years (TCCs),
P = 0.001. Significantly more patients with TCC had atrial fibrillation than patients with grafts (30.3%
versus 6.5%, P = 0.01). In an unadjusted Kaplan–Meier analysis, median TCC survival at 24 months
was 5.4 months longer than that of PTFE grafts but not significantly (log-rank test = 1.3, P = ns). In a
Cox regression analysis adjusted for age, gender, number of previous vascular accesses, diabetes,
atrial fibrillation, smoking, and any complication, this lack of significant difference in survival of the
vascular access between TCC and PTFE groups was confirmed and diabetes proved to be an
independent risk factor for the survival of both vascular accesses considered (P = 0.02). In an
unadjusted Kaplan–Meier analysis, a higher mortality was found in the TCC group than in the PTFE
group at 24 months (log-rank test = 10.07, P < 0.01). The adjusted Cox regression analysis showed
that patients with TCC had a 3.2 times higher risk of death than patients with PTFE grafts. When an
arteriovenous fistula (AVF) is not possible, PTFE grafts can be considered the vascular access of
second choice, whereas TCCs can be used when an AVF or PTFE graft are not feasible or as a
bridge to AVF or PTFE graft creation.
COMMENTS
Native arteriovenous fistula (AVF) is still the vascular access of choice in hemodialysis. Other
options are arteriovenous grafts (AVGs) or tunneled cuffed permanent catheters (TCCs) when it is
not possible to create an AVF. These alternative vascular accesses have gained more attention
because of the increasing age and comorbidities of the hemodialysis population and the late referral
to nephrologists, and the timing of vascular access creation.
When the native vessels available for AVF have been exhausted, a second choice vascular access
is needed.
The aim of this study was to compare AVGs and TCCs as a second choice vascular access, in
terms of survival of both the patient and the vascular access at 12 and 24 months of hemodialysis.
The AVGs were made of polytetrafluoroethylene (PTFE; GORE-TEX, W. L. Gore & Associates,
Flagstaff, AZ, USA) and had been created by the vascular surgeon. In 24 patients, the AVG was
placed between the brachial artery and the brachial vein, in three cases between the brachial artery
and the cephalic vein. Nineteen PTFE grafts had an internal diameter of 6 mm, and three PTFE
grafts had an internal diameter of 7 mm. Nine grafts had a conic feature, five of them had 6-mm
diameter in the venous side and 4-mm diameter in the arterial side, four had a 7-mm diameter on
the venous side and 4-mm diameter in the arterial side. In 19 cases out of 31 (61.3%), the PTFE
grafts were placed in the arm where a previous native vessel AVF had been created and failed. In
12 cases out of 31 (38.7%), no native vessel AVF had been created before PTFE graft placement. A
period of 4 weeks was required between PTFE graft placement and the first cannulation.
All the patients received antithrombotic or anticoagulant therapy. The two groups did not differ in
terms of gender, diabetes, hypertension, ischemic cardiac injury, cerebral and peripheral
arteriopathy, or Charlson score. Before PTFE graft or TCC creation, the patients considered
underwent 182 AVF creations. The reasons for AVF failure were: thrombosis of the AVF perianastomotic site in 147/182 cases (81%), thrombosis of the efferent vein in 28/182 cases (15%),
and steal syndrome in 7/182 cases (4%).
The results of the present study indicate that the 2-year access survival of PTFE grafts and TCCs
was similar. Diabetes and any vascular access complication proved to be significant risk factors for
access survival. As to patient survival at 24 months, patients with TCC had a higher risk of death
than patients with a PTFE graft. The multivariate analysis confirmed that TCC was a significant risk
factor together with atrial fibrillation.
The study has several limitations since groups of patients were nor randomly defined, and their
number is small. Nevertheless these results refer to basic medical practice and have to be taken
into account.
In short, vascular access is the main risk factor for 24-months mortality of chronic hemodialysis
patients. Of the two types of vascular access considered, the PTFE graft carried a lower risk of
death than the tunneled cuffed catheter. The TCC can be used as a third choice when an
arteriovenous fistula or PTFE graft is not feasible or as a bridge to AVF or arteriovenous graft
creation and maturation. In terms of vascular access survival, the PTFE graft is no better than TCC.
Diabetes is the main risk factor for the survival of both vascular accesses considered.
Pr. Jacques CHANARD
Professor of Nephrology