Antiplatelet and Anticoagulation Impact on Patients with Lower Extremity Arteriovenous Dialysis Access

Lower extremity (LE) access remains a last resort for many patients needing dialysis. The role antiplatelet or anticoagulation (AC) therapy play in their patency is unknown. We sought to identify the effects of antiplatelet or AC therapy prescribed at discharge on patency and survival in patients undergoing creation of LE dialysis access.

All patients in the Vascular Quality Initiative dialysis module with a LE arteriovenous (AV) fistula (AVF) or AV graft (AVG) created from 2011 to 2023 were retrospectively analyzed. Medications prescribed at discharge were organized into aspirin (ASA), clopidogrel, dual antiplatelet therapy (DAPT), and single antiplatelet therapy plus anticoagulation (SAPT + AC). Univariable Kaplan-Meier (KM) and multivariable regression analyses were utilized to assess impact of discharge medication on survival and primary/secondary patency.

A total of 1,190 patients underwent LE dialysis access creation with 151 (12.7%) receiving AVFs and 1,039 (87.3%) receiving AVGs. Of AVF patients, 41 (27.2%) were discharged on no medication, 50 (33.1%) on ASA, 5 (3.3%) on clopidogrel, 9 (6.0%) on DAPT, and 46 (30.5%) on SAPT + AC. Following AVG creation, 348 (33.5%) of patients were discharged on no medications, 271 (26.1%) on ASA, 59 (5.7%) on clopidogrel, 62 (6.0%) on DAPT, and 299 (28.8%) on SAPT + AC. KM analyses showed no difference in survival, primary patency, or secondary patency based on medication following AVF. Multivariable analysis showed improved secondary patency with clopidogrel alone (hazard ratio, 0.08; confidence interval, 0.01-0.96; P = 0.04). ASA, DAPT, and SAPT + AC use showed no significant difference.

This analysis suggests SAPT is protective for LE AVG with clopidogrel alone showing statistically significant protection. This suggests that clopidogrel as SAPT is a viable option for prolonging AVG patency if prescribed at discharge. Further study on antiplatelet usage following LE dialysis access creation is warranted.