General anesthesia is associated with reduced early failure among patients undergoing hemodialysis access

Despite recent reports of improved patency with regional anesthesia (RA), general anesthesia (GA) remains the most common choice for anesthesia for patients undergoing arteriovenous fistula (AVF) or arteriovenous graft (AVG) creation, with nearly 85% utilization. Previous studies of the effect of anesthesia type on outcomes have been conducted through single institutions or a national database with poor granularity for vascular-specific data. Given the high variability of practice patterns and the high prevalence of end-stage renal disease requiring access creation, further study of the impact of anesthesia choice during AVF or AVG creation is warranted.

The Vascular Quality Initiative hemodialysis data set was queried to identify patients undergoing AVF or AVG creation between 2011 and 2017. Patients were grouped according to access type and anesthesia method (GA vs local anesthesia/RA). The primary outcome was early access failure within 120 days. Secondary outcomes were in-hospital and 30-day complications, including steal, swelling, hemorrhage, and wound infection.

There were 31,028 patients undergoing AVG (6961) or AVF (24,067) identified. Compared with patients with GA, patients undergoing access creation with RA had higher early failure rates (AVG, 26.2% vs 23%; AVF, 22.3% vs 20.6%; both P = .04). However, in the GA group undergoing AVF creation, there was a 26% increase (adjusted odds ratio, 1.26 [1.06-1.55]) in bleeding complications and a 3.4-fold increase (adjusted odds ratio, 3.43 [1.38-8.51]) in wound infection rates.

Whereas it is traditionally performed under GA, hemodialysis access with fistula or graft creation is increasingly being performed under RA. In our analysis, rates of perioperative complications, including infection and bleeding, may be lessened by using RA, especially among patients undergoing AVF creation. However, this was accompanied by a 3.2% absolute (21% relative) increased risk of early failure within the first 120 days after dialysis creation among patients undergoing AVG.