Comparison of Arteriovenous Grafts in the Thigh and Upper Extremities in Hemodialysis Patients
Christopher D. Miller*,
Michelle L. Robbin,
Jill Barker and
Michael Allon*
*Division of Nephrology and Department of Radiology, Division of Ultrasound, University of Alabama at Birmingham, Birmingham, Alabama; and Statistical Consulting of Montana, Bozeman, Montana
Correspondence to Dr. Michael Allon, Division of Nephrology, PB, Room 226, 728 Richard Arrington Boulevard, Birmingham, AL 35233. Phone: 205-975-9676; Fax: 205-975-8879;
ABSTRACT. Placement of a thigh graft is an option in hemodialysispatients who have exhausted all upper extremity sites for permanentvascular access. The outcome of thigh grafts has been reportedonly in retrospective studies. The outcomes of 409 grafts placedat a single institution during a 3.5-yr period were evaluatedprospectively, including 63 thigh grafts (15% of the total).Information was recorded on surgical complications, dates ofradiologic and surgical interventions, and date of graft failure.The technical failure rate was approximately twice as high forthigh grafts, as compared with upper extremity grafts (12.7versus 5.8%; P = 0.046). Intervention-free survival was similarfor thigh and upper extremity grafts (median, 3.9 versus 3.5mo; P = 0.55). Thrombosis-free survival was also comparablefor thigh and upper extremity grafts (median, 5.7 versus 5.5mo; P = 0.94). Cumulative survival (time to permanent failure)was similar for thigh and upper extremity grafts (median, 14.8versus 20.8 mo; P = 0.62). When technical failures were excluded,the median cumulative survival was 27.6 mo for thigh graftsand 22.5 mo for upper extremity grafts (P = 0.72). The frequencyof angioplasty (0.28 versus 0.57 per year), thrombectomy (1.58versus 0.94 per year), surgical revision (0.28 versus 0.18 peryear), and total intervention rate (2.15 versus 1.70 per year)was similar between thigh and upper extremity grafts. Accessloss as a result of infection tended to be higher for thighgrafts than for upper extremity grafts (11.1 versus 5.2%; P= 0.07). In conclusion, placement of thigh grafts should beconsidered a viable option among hemodialysis patients who haveexhausted all options for a permanent vascular access in bothupper extremities. E-mail mdallon@uab.edu
K/DOQI guidelines on vascular access recommend preferentialplacement of arteriovenous (A-V) fistulas in hemodialysis patients,with A-V grafts reserved for patients whose vascular anatomyprecludes fistula placement (1). The rationale for this recommendationis that fistulas require substantially fewer interventions thando grafts to maintain long-term patency for dialysis (2). Notwithstandingthese practice guidelines, the majority of hemodialysis patientsin the United States continue to dialyze with grafts (3–5).A subset of patients experience multiple vascular access failuresto the point that they exhaust options for further permanentvascular access in the upper extremities. In such patients,continued hemodialysis requires either placement of a thighgraft (interposed between the common femoral artery and thecommon femoral vein) or prolonged use of tunneled dialysis catheters.Given the frequent infectious and thrombotic complications ofdialysis catheters (6), a thigh graft would seem to be the betteroption. However, the long-term outcomes of thigh grafts amonghemodialysis patients has been reported only in retrospectiveseries (7–12), only two of which provided a comparisonwith a concurrent group of upper extremity grafts (8,11).
Since 1996, we have been using an efficient, multidisciplinaryapproach to hemodialysis access (13). One of the hallmarks ofthis approach has been centralized scheduling of all vascularaccess procedures by a dialysis access coordinator, who maintainsprospective, computerized records. This computerized databasewas used to track the outcomes, complications, and interventionsfor all vascular accesses in our dialysis population. The currentstudy compared the short- and long-term outcomes of thigh graftswith those obtained in upper extremity grafts.
Patient Population
The University of Alabama at Birmingham (UAB) provides chronicdialysis to approximately 550 patients incenter hemodialysispatients at six dialysis units in metropolitan Birmingham. Thedemographics of our dialysis patient population are as follows:29% of the patients are age 65 or older; 49% of the patientsare female; 82% of the patients are black, and 18% are white;and 54% of the patients have diabetes. Despite a concerted effortto increase the proportion of patients who dialyze with fistulas(14), approximately 50% of patients used grafts during the studyperiod. The medical care of these patients is provided by 10clinical nephrologists, all full-time university faculty inthe Division of Nephrology. All patient hospitalizations, surgicalprocedures, and radiologic procedures are done at UAB Hospital.Vascular access procedures are performed by the transplant surgeonsand radiologic diagnostic tests and interventions for vascularaccess are performed by members of the Department of Radiology.Two full-time dialysis access coordinators schedule all dialysisaccess procedures with both surgery and radiology and serveas the liaison between the nephrologists, surgeons, radiologists,and dialysis staff, thereby providing consistency of communication(13).
Management of Dialysis Grafts and Their Complications
All A-V grafts were constructed by one of three experiencedtransplant surgeons during the 3.5-yr study period (January1, 1999, to June 30, 2002). There was no overlap with a seriesof grafts previously reported from our institution (15). A concertedeffort was made to attempt an A-V fistula, rather than a graft,whenever the surgeon believed that the vessels were suitablefor fistula construction (14). A graft was constructed onlywhen the patient had no suitable vessels for a fistula. Theclinical assessment of the adequacy of the vessels was determinedby the surgeon after reviewing the results of preoperative sonographicvascular mapping (2,14,16). We have previously reported thatamong patients who received their first vascular access, graftplacement was required in only 23%. However, 61% of patientswho received a secondary vascular access required A-V graftplacement (14). Before placing a thigh graft, the surgeons performeda detailed clinical evaluation of the lower extremity circulation.In some cases, they ordered noninvasive studies or an arteriogramas part of the preoperative evaluation. When there was evidencefor clinically significant peripheral vascular disease, thesurgeons declined to place a thigh graft. A-V grafts were cannulatedinitially for dialysis 2 to 3 wk after their placement.
Clotted grafts were referred primarily to interventional radiologyfor mechanical thrombectomy in conjunction with angioplastyof hemodynamically significant stenotic lesions (17). When thethrombectomy was unsuccessful, a tunneled internal jugular dialysiscatheter was placed under ultrasound guidance during the sameprocedure. Detailed definition of the relevant vascular anatomypermitted the surgeon to plan the optimal access procedure whenthe thrombectomy was unsuccessful. Surgical thrombectomy wasperformed in a small number of cases when thrombosis occurredwithin 1 mo of graft construction.
For decreasing the frequency of graft thrombosis, aggressiveclinical surveillance for evidence of graft stenosis was implemented(13). Patients were referred to interventional radiology fora fistulogram when any of the following abnormalities was noted:(1) persistent elevation of dialysis venous pressures (DVP)at a low blood flow during initiation of dialysis, (2) prolongedbleeding from needle puncture sites in the graft, (3) unexplainedprogressive decrease in Kt/V, or (4) abnormal graft inspectionand auscultation (18). We have previously reported that aggressiveclinical monitoring of grafts and referral for a fistulogramwhen any one of these abnormalities was detected decreased thefrequency of graft thrombosis by 60% (13).
Angioplasty of the stenotic lesion was attempted when it wasthought to be hemodynamically significant (17). When the stenoticlesion was not amenable to angioplasty or failed to improvewith angioplasty, the patient was referred for surgical revision(bypass graft). Grafts that clotted twice in 1 mo as a resultof recurrent stenosis were also referred for surgical revision.Grafts were considered to have failed permanently when the vascularanatomy precluded surgical revision to restore graft patency.This could be due to a very long stenotic lesion in the graftor draining vein that did not respond to angioplasty, a venousocclusion in the very proximal upper extremity, a central veinlesion that could not be corrected radiographically, extensivegraft pseudoaneurysm formation, or serious graft infection.Once a graft failed, the surgeons placed a new vascular accessat a different site.
Statistical Analyses
All information regarding placement of new A-V grafts and subsequentgraft complications and interventions was maintained prospectivelyin a computerized file maintained by the dialysis access coordinators(13). Consent to review the clinical database for research purposeswas obtained from our Institutional Review Board. Our InstitutionalReview Board does not require an informed consent for such recordreview. Intervention-free graft survival was defined as thetime interval from graft placement until the first graft intervention(thrombectomy, angioplasty, or surgical revision) or failure.Thrombosis-free graft survival was defined as the time fromgraft placement to first thrombosis or failure. Cumulative graftsurvival was defined as the time interval from initial graftplacement until it could no longer be used for dialysis, regardlessof how many interventions were required to maintain graft patency.Censored end points for analysis included death, transplant,loss to follow-up, and graft survival to the end of the studyperiod (August 31, 2002). Survival distributions were plottedusing the Kaplan-Meier method for intervention-free graft survival,thrombosis-free graft survival, and cumulative graft survival(19). Log rank tests were used to evaluate for statistical differencesin survival distribution between thigh grafts and upper extremitygrafts.
The patients’ medical records were also reviewed for thefollowing demographic and clinical variables: age, gender, race,years on dialysis, number of previous vascular accesses, diabetes,coronary artery disease, peripheral vascular disease, cerebrovasculardisease, congestive heart failure, and history of a previousipsilateral dialysis catheter. Comparison of the survival curvesbetween upper extremity and thigh grafts was repeated afterstatistical adjustment for these multiple factors.
Graft salvage procedures were classified into one of three categories:thrombectomies, angioplasties, and surgical revisions. The frequencyof graft interventions was calculated as the ratio between thenumber of interventions performed and the duration of follow-up(in graft-years). Because these frequencies were not normallydistributed, Mann-Whitney U tests were used to compare interventionrates between thigh and upper extremity grafts (20).
We analyzed the outcomes of all grafts placed in UAB dialysispatients during the 3.5-yr period from January 1, 1999 to June30, 2002. A total of 409 grafts were placed: 346 in the upperextremities and 63 in the thighs. Thus, thigh grafts accountedfor approximately 15% of all grafts placed during the studyperiod. Table 1 summarizes the clinical characteristics of thepatients who received grafts. Patients who received a thighgraft had a similar age, race, and gender distribution to thosewho received upper extremity grafts but were significantly lesslikely to have diabetes. Not surprising, patients who receiveda thigh graft had a significantly higher number of previousvascular accesses than those who received an upper extremitygraft. Moreover, the mean time on dialysis at the time of accessplacement was >2 yr longer for thigh grafts than for upperextremity grafts. Approximately one third of patients with anupper extremity graft had had a previous ipsilateral dialysiscatheter. The frequency of vascular disease was not significantlydifferent between patients who received thigh grafts and thosewith upper extremity grafts, although peripheral vascular diseaseand cerebrovascular disease tended to be less frequent in theformer group. Using multiple variable logistic regression, thelikelihood of having a thigh graft was independently predictedby only two factors: absence of diabetes (odds ratio, 2.51 [1.36to 4.66] and years on dialysis (odds ratio, 1.09 [1.02 to 1.15]per year on dialysis).
Table 1. Clinical features of patients with thigh versus upper extremity graftsa
The graft outcome was indeterminate in 17 cases (approximately4% of the total) as a result of either early death or transferto a dialysis unit outside of UAB within 1 wk of graft placement.The remaining 392 grafts were evaluated for subsequent outcomes.Twenty-eight graft placements (6.8% of the total) were technicalfailures (they could not be placed because of inadequate vesselsduring the surgical exploration or clotted immediately afterthe surgical anastomosis was completed). The technical failurerate was approximately twice as high for thigh grafts, as comparedwith upper extremity grafts (12.7 versus 5.8%; P = 0.046). Sevenpatients with mild peripheral vascular disease had a thigh graftplaced after careful clinical assessment by the surgeon. Nopatient developed ischemic changes in the limb after thigh graftplacement.
The intervention-free survival was similar for thigh and upperextremity grafts (Figure 1A). The median survival was 3.9 mofor thigh grafts and 3.5 mo for upper extremity grafts (hazardratio, 0.91; 95% confidence interval, 0.67 to 1.25). Thrombosis-freesurvival was also comparable between the two graft locations(Figure 1B). The median survival was 5.7 mo for thigh graftsand 5.5 mo for upper extremity grafts (hazard ratio, 1.01 [0.72to 1.43]). Finally, the cumulative survival was similar forthigh grafts and upper extremity grafts (Figure 2A). The mediancumulative survival was 14.8 mo for thigh grafts and 20.8 mofor upper extremity grafts (hazard ratio, 1.11 [0.74 to 1.69]).When technical graft failures were excluded, the median cumulativesurvival was 27.6 mo for thigh grafts and 22.5 mo for upperextremity grafts (hazard ratio, 0.91 [0.56 to 1.49]; Figure 2B).
Figure 1. (A) Intervention-free graft survival comparing patients with thigh grafts with those with upper extremity grafts; P = 0.55 for the comparison between the two survival curves. (B) Thrombosis-free graft survival comparing patients with thigh grafts with those with upper extremity grafts; P = 0.94 for the comparison between the two survival curves. Technical failures and grafts that were never useable for dialysis are included in the analysis.
Figure 2. Cumulative graft survival comparing patients with thigh grafts with those with upper extremity grafts, with inclusion of technical failures (A), or after exclusion of technical failures (B); P = 0.62 and 0.72 for the comparison between the two survival curves in the two panels, respectively.
A comparison of the survival curves for thigh and upper extremitygrafts was repeated after statistical adjustment for the followingfactors: age, gender, race, diabetes, peripheral vascular disease,coronary artery disease, cerebrovascular disease, congestiveheart failure, years on dialysis, and history of previous ipsilateraldialysis catheter. There was no difference between intervention-freesurvival, thrombosis-free survival, or cumulative graft survival,whether technical failures were included or excluded (Table 2).
Table 2. Adjusted hazard ratios for outcomes of thigh grafts relative to upper extremity graftsa
Patients who received thigh grafts were much less likely tohave diabetes than those who received upper extremity grafts(Table 1). It is possible that the outcomes of thigh graftsare actually worse than that of upper extremity grafts, butthe difference is obscured by the lower prevalence of diabetesamong patients who received a thigh graft. To evaluate thispossibility, we compared the cumulative graft survival betweenpatients with and without diabetes. The median cumulative survivalwas 22.5 and 19.4 mo, respectively (P = 0.79).
There were a total of 344 graft-years of follow-up in the presentstudy. To maintain graft patency required a mean of 1.77 interventions,including 0.52 angioplasties, 1.04 thrombectomies, and 0.20surgical revisions per graft-year. The frequency of salvageprocedures was not significantly different between thigh andupper extremity grafts, although thigh grafts tended to undergofewer angioplasties and more thrombectomies (Table 3).
In the course of the study, 171 grafts failed permanently, 146(85%) as a result of thrombosis and 25 (15%) as a result ofinfection. Seven thigh grafts and 18 upper extremity graftsfailed as a result of infection. Access loss as a result ofinfection tended to be higher for thigh grafts than for upperextremity grafts (11.1 versus 5.2%; P = 0.07). The infectionrate was 0.13 per patient-year for thigh grafts and 0.07 forupper extremity grafts.
We observed similar outcomes of thigh and upper extremity graftsin a well-defined hemodialysis population with prospective trackingof outcomes. This was true, whether one compared intervention-freesurvival (Figure 1A), thrombosis-free survival (Figure 1B),or cumulative graft survival (Figure 2A) between graft sites.Moreover, the graft outcomes did not differ when technical failureswere excluded from the analysis (Figure 2B). Because this wasnot a randomized study, patients who received a thigh graftdiffered in several ways from those who received an upper armgraft (Table 1). However, even after adjusting for other demographicand clinical factors in the multivariable model, there was nosignificant difference in outcomes between thigh and upper extremitygrafts (Table 2). Finally, with careful preoperative screening,no patient developed limb ischemia after placement of a thighgraft.
The long-term outcome of thigh grafts has been reported previouslyonly in retrospective studies (Table 4). Cumulative graft survivalin the present study was similar to that found by Khadra etal. (11) but lower than that in three other series (7,9,12).In a retrospective comparison, Zibari et al. (8) reported amean patency of 1.5 yr for thigh grafts, as compared with 1.9yr for upper extremity grafts. Most of the retrospective studiesdo not state whether technical failures or graft loss to infectionwere included in calculation of cumulative survival. Exclusionof these events would suggest an overly optimistic graft outcome.Thus, for example, Tashjian et al. (12) observed an 83% thrombosis-freesurvival at 2 yr (censoring for loss as a result of infection)and a 76% infection-free survival at 2 yr (censoring for lossas a result of thrombosis). Combining the two events would yieldan overall cumulative graft survival of 59% at 2 yr.
Table 4. Outcomes of thigh grafts in the literaturea
Diabetes was less common among patients who received thigh graftsthan in those with upper extremity grafts. This difference islikely due to the shorter dialysis patient survival in individualswith than without diabetes (21) and the longer duration on dialysisbefore a patient would be considered for a thigh graft (Table 1).In other words, fewer dialysis patients with diabetes livelong enough to exhaust all options for upper extremity vascularaccess. Nevertheless, the difference in frequency of diabeteswas unlikely to be a confounding variable affecting the relativesurvival of thigh and upper extremity grafts, given the similarcumulative graft survivals that we observed in patients withand without diabetes.
Both thigh and upper extremity grafts required a high frequencyof elective angioplasty, thrombectomy, and surgical revisionto maintain their long-term patency for dialysis (Table 3).The major cause of graft failure is thrombosis as a result ofocclusion of the venous anastomosis, draining vein, or centralvein (22). Myointimal hyperplasia is the initial pathophysiologicevent leading to graft stenosis. In the absence of prophylacticmeasures to prevent myointimal hyperplasia, most grafts developprogressive stenosis. When the stenosis is not detected andcorrected in a timely manner, grafts typically clot and requirethrombectomy to restore their patency. A number of studies havefound that an ongoing surveillance program for graft stenosisand timely intervention with angioplasty or surgical revisioncan substantially reduce (but not eliminate) the frequency ofgraft thrombosis (13,23–26). In the present study, thighgrafts tended to have less frequent angioplasties and more frequentthrombectomies than did upper extremity grafts (Table 3). Thesedifferences suggest that clinical monitoring for graft stenosismay be less sensitive for thigh grafts than for upper extremitygrafts, although this specific question has not been addressedin the medical literature.
Because of their proximity to the groin, thigh grafts mightbe thought to be more prone to infection than upper extremitygrafts. In fact, we found a trend (P = 0.07) of higher riskof infection with thigh grafts. The frequency of thigh graftinfection that we observed was in the low end of that observedin several previous retrospective studies (Table 4). In a retrospectivecomparison, Zibari et al. (8) reported an infection in 12.5%of thigh grafts versus 16.7% of upper extremity grafts.
In conclusion, the performance of thigh grafts is comparableto that of upper extremity grafts. Despite a significantly highertechnical failure rate, intervention-free survival, thrombosis-freesurvival, and cumulative survival were similar between thighand upper extremity grafts. The thigh graft infection rate of0.13 per patient-year that we observed is far lower than thatreported for tunneled dialysis catheters (0.7 to 2.0 per patient-year,or 2.0 to 5.5 per 1000 patient-days) (27–32). The thighgraft thrombosis rate of 1.58 per patient-year compares favorablyto that reported for tunneled dialysis catheters (3.0 to 3.2per patient-year, or 8.1 to 8.8 per 1000 patient-days) (28,33).The cumulative thigh graft survival rate at 1 yr (62%) is substantiallyhigher than the corresponding 9% rate reported for tunneleddialysis catheters (34). Finally, the median dialysis bloodflow delivered by grafts is substantially higher than that obtainedwith catheters, thereby enhancing dialysis adequacy (6). Forall of these reasons, placement of thigh grafts should be considereda viable option among hemodialysis patients who have exhaustedall options for a permanent vascular access in both upper extremitiesand is certainly far preferable to the long-term use of a tunneleddialysis catheter. Because our results reflect the outcomesat a single institution, they may not generalize to all dialysiscenters.
Acknowledgments
This study was supported in part by National Institute of Diabetesand Digestive and Kidney Diseases Grant 1 K24 DK59818-01 toDr. Allon. We thank our dialysis access coordinators Donna Carltonand Lisa Bimbo for maintaining the computerized database ofaccess procedures.
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Received for publication May 5, 2003.
Accepted for publication July 24, 2003.
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Abstract
Introduction
