Comparative effectiveness of one-stage versus two-stage basilic vein transposition arteriovenous fistulas

Basilic vein transposition (BVT) fistulas may be performed as either a one-stage or two-stage operation, although there is debate as to which technique is superior. This study was designed to evaluate the comparative clinical efficacy and cost-effectiveness of one-stage vs two-stage BVT.

We identified all patients at a single large academic hospital who had undergone creation of either a one-stage or two-stage BVT between January 2007 and January 2015. Data evaluated included patient demographics, comorbidities, medication use, reasons for abandonment, and interventions performed to maintain patency. Costs were derived from the literature, and effectiveness was expressed in quality-adjusted life-years (QALYs). We analyzed primary and secondary functional patency outcomes as well as survival during follow-up between one-stage and two-stage BVT procedures using multivariate Cox proportional hazards models and Kaplan-Meier analysis with log-rank tests. The incremental cost-effectiveness ratio was used to determine cost savings.

We identified 131 patients in whom 57 (44%) one-stage BVT and 74 (56%) two-stage BVT fistulas were created among 8 different vascular surgeons during the study period that each performed both procedures. There was no significant difference in the mean age, male gender, white race, diabetes, coronary disease, or medication profile among patients undergoing one- vs two-stage BVT. After fistula transposition, the median follow-up time was 8.3 months (interquartile range, 3-21 months). Primary patency rates of one-stage BVT were 56% at 12-month follow-up, whereas primary patency rates of two-stage BVT were 72% at 12-month follow-up. Patients undergoing two-stage BVT also had significantly higher rates of secondary functional patency at 12 months (57% for one-stage BVT vs 80% for two-stage BVT) and 24 months (44% for one-stage BVT vs 73% for two-stage BVT) of follow-up (P < .001 using log-rank test). However, there was no significant difference between groups in use of interventions (58% for one-stage BVT vs 51% for two-stage BVT; P = .5) to maintain patency. These findings were confirmed in multivariate analysis, in which two-stage BVTs were associated with a significantly lower rate of failure (hazard ratio, 0.39; 95% confidence interval, 0.2-0.8; P < .05) than one-stage BVTs after controlling for confounding variables. Finally, the two-stage BVT was more cost-effective (3.74 QALYs for two-stage BVT vs 3.32 QALYs for one-stage BVT) during 5 years, with an incremental cost-effectiveness ratio of $4681 per QALY.

Our data show that two-stage BVTs are more durable and cost-effective than one-stage procedures, with significantly higher patency and lower rates of failure among comparable risk-stratified patients. These findings suggest that additional upfront costs and resources associated with creating two-stage BVTs are justified by their long-term outcomes.