Vascular Access Management in Patients on Catheter-Based Hemodialysis

Background/Objectives: Hemodialysis (HD) is a life-sustaining treatment for an increasing number of patients around the globe. The options for vascular access (VA) in HD are arteriovenous fistulas (AVFs), arteriovenous grafts (AVGs), and central venous catheters (CVCs). AVFs are historically associated with better long-term outcomes. Recently, international guidelines have shifted to a more individualized approach driven by evidence that patient-specific factors influence the success of AVF creation. The initial "Vienna ACTS NOW" study revealed significant inter-center variability in CVC prevalence in Vienna. This two-year follow-up aimed to document the continuing variability in CVC-based HD management and to monitor the clinical outcomes and cost associated with an attempted conversion to AVF/G. Methods: This multi-center cohort study collected data (March 2023 to March 2025) on 153 CVC-based HD patients from six Viennese institutions. Primary endpoints included VA-related events and patency; the secondary endpoint was overall mortality. Costs were calculated using the Austrian Catalogue for Medical Services (MEL). Results: Overall, 28 (18.3%) out of 153 patients underwent AVF/G surgery, and 20 (71.4%) achieved successful cannulation. A total of 12 surgical and 14 endovascular interventions were performed to either support VA maturation or maintain patency. The median hospital admission was 3 days for VA creation and 4 days for later interventions. VA creation in patients that did not require later interventions cost 3130.44 € per patient, and it cost 11,893.02 € in patients that did. The proportion of AVF/G creation attempts varied from 0% to 40.9% between centers. Patients who underwent VA-creating surgery had a better rate of survival after two years compared to patients who did not undergo VA-creating surgery. (86.2% vs. 63.3% p < 0.02). Overall, 6.3% of deaths were related to VA management. Conclusions: Patient-specific characteristics and the capability of the healthcare system to timely detect and treat CKD might influence the outcome of patients. The proportion of CVC- and AVF/G-based HD might therefore be associated with the level of access patients have to the healthcare system and the efficiency of the care network. Our own data point towards a difference in CVC use between different centers in Vienna, not solely driven by patient characteristics, but by locally available resources and differences in policies.