RS04 - When Fistula-First Is Not First: Hemodialysis Access Patency in Patients Aged 80 Years and Older

Objectives: In general, arteriovenous fistulas (AVFs) are the preferred choice for hemodialysis access over arteriovenous grafts (AVGs) due to their superior long-term durability and lower infection rates. However, this “fistula-first" approach may need re-evaluation for older patients (over age 80) who require a basilic vein transposition (BVT) due to inadequate cephalic vein. In this specific population, the benefits of AVFs are less clear due to higher competing risks, the increased burden of reinterventions, and the longer time required for a BVT become ready for cannulation as compared to AVG. We hypothesize that for patients over the age of 80, the primary, primary-assisted, and secondary patency rates between BVT and AVGs will be similar.

Methods: We performed a retrospective review of patients aged ≥80 years who underwent hemodialysis access creation between 2019 and 2024. The cohort included 214 accesses (143 AVGs and 71 BVTs) performed by 14 surgeons across 8 hospitals. Patients lost to follow-up (11 AVGs, 9 BVTs) were excluded from longitudinal patency analyses. Primary endpoints were 30-day, 1-year, and 3-year access patency. Secondary endpoints included 30-day surgical complications.

Results: After exclusions, longitudinal patency outcomes were analyzed for 194 accesses. Overall complication rates were similar between groups, although patients receiving AVGs were more likely to have had prior access surgery. (Table I) Primary patency at 30 days was high for both access types (87.2% AVG vs 95.7% BVT, p=0.053) but declined substantially over time, reaching 29.0% versus 35.9% at 1 year (p=0.377) and 6% versus 0% at 3 years (p=0.552). Primary-assisted patency was also similar between groups, with 30-day rates of 91.5% versus 98.6% (p=0.065), 1-year rates of 54.2% versus 69.8% (p=0.059), and 3-year rates of 28% versus 25% (p=0.799). Secondary patency did not differ significantly, with 30-day rates of 95.7% versus 100% (p=0.181), 1-year rates of 86.0% versus 90.6% (p=0.409), and 3-year rates of 58% versus 45% (p=0.324). (Figure I)

Conclusions: In patients aged 80 years or older, BVTs did not demonstrate superior primary, primary-assisted, or secondary patency compared with AVGs. While early patency was high for both access types, long-term durability declined markedly regardless of configuration. These findings suggest that in octogenarians without an adequate cephalic vein, a routine fistula-first strategy may not provide a meaningful long-term advantage over AVGs.