Should fistulas really be first in the elderly patient?

Area of Science:

• Nephrology
• Vascular Surgery
• Geriatrics

Background:

• Current Kidney Disease Outcomes and Quality Initiative (K/DOQI) guidelines recommend arteriovenous fistulas (AVF) for most patients needing permanent vascular access.
• These guidelines do not specify demographic considerations, particularly for elderly populations.

Purpose of the Study:

• To analyze the surgical outcomes of permanent vascular access in patients aged 70 years and older.
• To evaluate the efficacy and safety of first-time AVF procedures in elderly individuals.

Main Methods:

• Retrospective review of consecutive patients undergoing first-time permanent access procedures (January 2005 - December 2005).
• Exclusion of patients with prior permanent Arteriovenous (AV) access attempts.
• Kaplan-Meier curves used to determine patency rates.

Main Results:

• Elderly patients (≥70 years) showed significantly lower 12-month primary assisted patency (35% vs. 67%) and secondary patency (36% vs. 67%) compared to younger patients.
• Mortality was higher in the elderly group (48% vs. 20%), with 18-month survival at 50% versus 74% for younger patients.
• Access to AVF was limited in elderly patients who died, averaging only 8 accessible AVFs.

Conclusions:

• The study highlights increased mortality and decreased patency rates for AVF in elderly patients (over 70).
• These findings challenge the universal application of K/DOQI guidelines for AVF in this specific patient subgroup.
• Autogenous fistulas may not be the optimal first-line vascular access choice for elderly patients.