VESS14 - Comparative outcomes of forearm versus upper arm arteriovenous fistulas in patients with diabetes: a secondary analysis of prospective multicenter clinical trials

Wednesday, June 10, 2026

3:41 PM - 3:46 PM ET

Location: Hynes CC, Third Level, Room 304

Submitting & Presenting Author(s)

Christopher Holden-Wingate, BS

Medical Student
Brigham and Women's Hospital

Co-Author(s)

Mohit K. Manchella, BS

Medical Student
Harvard Medical School
Boston, Massachusetts
AH

Abraham Hussain

Brigham and Women's Hospital
AT

Aurelie Tran

Brigham and Women's Hospital
MR

Mengyuan Ruan

Brigham and Women's Hospital
HS

Helena Smith

Research Fellow
Richard A. and Susan F. Smith Center for Outcomes Research, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA
Boston, Massachusetts
AK

Amber Kernodle

Brigham and Women's Hospital
ES

Eric A. Secemsky

Assistant Professor
Richard A. and Susan F. Smith Center for Outcomes Research, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA
Boston, Massachusetts
Dirk M. Hentschel, MD

Director, Interventional Nephrology
Brigham and Women's Hospital
Boston, Massachusetts
CO

Charles Ozaki

Vascular and Endovascular Surgeon, John A. Mannick, M.D. Endowed Professor of Surgery
Brigham and Women's Hospital
Boston, Massachusetts

Senior Author(s)

Mohamad A. Hussain, MD, PhD

Vascular & Endovascular Surgeon, Associate Professor of Surgery
Brigham and Women's Hospital, Boston, MA
Boston, Massachusetts

Objectives: Although guidelines generally recommend a distal-first arteriovenous fistula (AVF) approach across most patient populations, patients with diabetes frequently have peripheral arterial occlusive disease that may limit forearm AVF success. We hypothesized that forearm AVFs are at increased risk for maturation failure and thrombosis compared with upper arm AVFs in patients with diabetes and advanced kidney disease.

Methods: We conducted a retrospective analysis of pooled data from three prospective multicenter clinical trials (PATENCY-1, PATENCY-2, and NIH HFM Study) from 2010–2019. Patients with diabetes undergoing arm AVF creation were included. The primary outcome was successful AVF use (adjudicated two-needle cannulation for ≥30 consecutive days). Secondary outcomes included primary, primary-assisted, and secondary patency, and reinterventions. Outcomes between forearm and upper arm AVFs were compared using multivariable logistic and Cox proportional hazards regression, adjusting for clinical covariates and trial.

Results: Of 1516 trial patients, 933 patients (61.5%) had diabetes (655 forearm AVFs, 278 upper arm AVFs). Mean (SD) age was 59 (11.6) years; 25.8% were female; 44.5% had insulin-dependent diabetes; and 48.0% were on dialysis at access creation. Successful AVF use was similar between forearm and upper arm groups at 6 months (59.2 % vs 60.2%; aOR 1.09; 95% CI 0.66-1.82) and 12 months (65.6 % vs 64.5%; aOR 1.13; 95% CI 0.67-1.90). There was also no difference in secondary patency by access location (Figure 1). At 12 months, primary, primary-assisted, and secondary patency were 34.9% vs. 33.8% (aHR 1.05; 95% CI 0.85-1.28), 72.3% vs. 76.8%, (aHR 1.12; 95% CI 0.84-1.50), and 76.2% vs. 79.8%, (aHR 1.13; 95% CI 0.81-1.56) respectively. Forearm AVFs in patients with diabetes were associated with lower reintervention rates for access related hand ischemia (0.6% vs. 5.8%) and thrombosis (3.4% vs. 6.8%), but higher rates of arterial inflow stenosis (6.9 % vs. 4.0 %) (Figure 2). Findings were not related to diabetes severity.

Conclusions: Among patients with diabetes, forearm AVFs demonstrate similar functional maturation and durability to upper arm AVFs with lower rates of ischemic and thrombotic complications, despite the need for more arterial inflow interventions. Diabetes alone should not preclude forearm AVF creation, which offers distinct advantages in this patient population.