1st Place Podium Winner
Nonleaching Poly-Sulfobetaine Surface Modification to Reduce Dialysis Related Catheter Malfunctions
Christopher Loose, PhD; Roger Smith, PhD; Zheng Zhang, PhD; Michael Brouchard; Jun Li, PhD; Gregory Brotske
Semprus BioSciences, Cambridge, Massachusetts
Purpose: Semprus BioSciences, in collaboration with Teleflex, is developing a chronic cuffed hemodialysis catheter with Semprus Sustain™ Surface Technology. The Semprus Sustain™ Technology is a non-leaching surface modification permanently bound on the inside and outside of the catheter surface to reduce platelet attachment and thrombus for long-term duration. In contrast, leaching technologies (e.g., silver) have a limited duration of activity. The chronic hemodialysis catheter with Semprus Sustain™ Technology is designed to reduce catheter malfunction, interventions and replacements, and deter in-efficiencies due to delayed treatments.
Materials and Methods: A modified CDC biofilm reactor was utilized for growing biofilms under shear stress using both Staphylococcus epidermidis and Escherichia coli with nutrient flow for a period of 24 hours followed by sonication and quantitative recovery (ASTM E2562 – 07). Samples were exposed to 56 days of 100% citrated human plasma at 37°C with weekly exchanges. A 90 day study with exposure to 50% fetal bovine serum at 37°C with weekly exchanges was also performed. Modified devices were tested in an industry standard two hour bovine flow loop thrombosis model. Thrombus was measured visually and quantitatively using radio-labeled platelet counts including after 56 days of plasma exposure. Surface modified and control 5Fr PIC catheters were bilaterally implanted within jugular veins of canines with visual scoring of catheter and vessel thrombus at 4 hours. To simulate clinical use, blood was withdrawn into lumen and held for 4-5 minutes, every 30 minutes over 4 hour periods with withdrawal pressure measured at each time point.
Results: The betaine modified polymers showed equivalent reductions in S. epidermidis biofilm attachment (96.8%) before and after 56 days of plasma exposure. They also showed a consistent 99% reduction in radiolabeled platelet attachment in a thrombosis model. After 90 days of serum exposure a 98.9% reduction in E. coli biofilm was measured using a comparable mCDC reactor, demonstrating a further prolonged effectiveness and broad spectrum activity. Quantification of thrombus accumulation demonstrated a significant 99% reduction in thrombus associated with polySB-modified PICC. Surface modified PICCs required less withdrawal pressure at the end of luminal blood hold.
Conclusion: The Semprus Sustain™ Surface Technology has shown multi-month 99% reduction in platelet adhesion, thrombus and biofilm attachment. This surface modification will be assessed in clinical studies targeting the reduction in vascular access catheter-related complications over an extended period of use, and the technology will be transitioned to a range of devices, including hemodialysis catheters.
2nd Place Podium Winner
Dialysis Access Venous Stenosis: Treatment with Balloon Angioplasty -30 Second Versus 1-Minute Inflation Times
Mohsen Elramah, MD, Alexander Yevzlin, MD, Maureen Wakeen, NP, Brad Astor, MPH, PhD, Janet Bellingham, MD, Micah Chan, MD
University of Wisconsin Hospitals, Madison, Wisconsin
Background: Significance of balloon inflation times in treatment of dialysis access venous stenoses are not well defined. There is only one published report comparing 1-min vs 3-min inflation times in dialysis access. Our objective is to examine retrospectively the effects of 30 sec vs 1-min balloon inflation times on primary assisted patency.
Method: Using retrospective char review, a total of 51 prevalent dialysis patients in the 30-sec group were compared with 24 patients in the 1-min group over a period of 5 years. A total of 178 interventions were done. We retrospectively compared outcomes of 3, 6 and 9-month primary assisted patency, and secondary patency between the two groups. *
Results: Demographics and baseline characteristics were similar between both groups and were matched for dialysis vintage. Over the first 3-months or immediate technical success, there was no difference between the two inflation groups (hazards ratio [HR]=0.87; 95% CI: 0.34-2.26; p=0.78). However, after 3-months and up to 9-months, there was a significant advantage to the 30-sec angioplasty group (hazards ratio [HR]=1.67; 95% CI: 1.06-2.63; p=0.03) (See Kaplan Meier figure). On Cox regression, more interventions (≥ 3) (HR=2.15; 95% CI: 1.23-3.77; p=0.007), age (HR=1.02; 95% CI: 1.01-1.03; p=0.001) and female gender (HR=1.33; 95% CI: 0.98-1.80; p=0.06) were associated with diminished primary patency.
Conclusion: This study shows for the first time that shorter inflation times may be associated with improved longer term access patency. Perhaps, longer inflation times induce more endothelial injury and in turn neointimal hyperplasia develops more aggressively 3-months after intervention. Given the increasing demands of maintaining access patency in the era of Fistula First and Medicare reform, the role of angioplasty times requires further study.
3rd Place Podium Winner
Hydrogen peroxide directly stimulates monocyte chemoattractant protein-1 (MCP-1) expression in vascular endothelial cells
Yong-Soo Kim, MD, PhD and Jeong-Sun Han, MD
Section of Interventional Nephrology, Division of Nephrology, The Catholic University of Korea College of Medicine, Seoul, Korea
Background: Oxidative stress and activation of chemokines including MCP-1 are known to be downstream mechanisms responsible for neointimal hyperplasia after creation of hemodialysis vascular access. Currently, however, the precise roles for individual reactive oxygen species (ROS) in mediating MCP-1 gene expression are poorly understood.
Methods: After stimulating the human umbilical vein endothelial cells with H2O2, cell viability, MCP-1 mRNA (by quantitative real-time PCR), MAPK activity (by Western blot), and transcription factors activities including NFkB and AP-1 (by Western blot) were measured. Intracellular ROS production was analyzed by confocal microscopy using 2’,7’-dichlorofluorescin diacetate (DCF-DA). apocynin and 2-thenoyltrifluoroacetone (TTFA) were used as anti-oxidants,
Results: Cell viability was over 90% when the cells were incubated with low concentration (< 0.5 mM) of H2O2 for short (< 4 hr) time, while it was less than 70% with high concentration (1 mM) of H2O2 or for long (> 8 hr) time. H2O2 stimulated MCP-1 mRNA expression in a dose- and time-dependent manner with a peak at 4 hr. Confocal microscopic analysis using DCF-DA showed the anti-oxidants, apocynin or TTFA, abolished H2O2-induced intracellular ROS production. When the cells were pre-incubated with anti-oxidants, H2O2-induced MCP-1 mRNA expression was significantly inhibited. H2O2 induced phosphorylation of p38 and JNK with a peak at 30 min, respectively. In addition, H2O2 induced phosphorylation of NFkB subunit, p65, and degradation of NFkB, and also induced phosphorylation of AP-1 subunits, c-Jun and c-Fos. When the cells were pre-incubated with SB203580 (P38 inhibitor), SP600125 (JNK inhibitor), pyrrolidine dithiocarbamate (PDTC, NFkB inhibitor), or curcumin (AP-1 inhibitor), H2O2-induced MCP-1 mRNA expression was completely inhibited.
Conclusion: These data suggest that reactive oxygen species directly stimulate MCP-1 expression in vascular endothelial cells through the p38, JNK (cytoplasmic) and NFkB, AP-1 (nuclear) pathways. This study provides a new insight into the potential of anti-oxidants to prevent neointimal hyperplasia in vascular access.
Buttonhole Cannulation versus Rope-ladder Technique and Hemodialysis Access Patency
Mohsen Elramah MD1 Alexander S Yevzlin MD1 Maureen Wakeen NP1, Xinliu Meyer NP1, Janet Bellingham MD2, Brad C. Astor PhD MPH1,3 Micah R Chan MD MPH1
1Division of Nephrology, Department of Medicine,
2 Division of Transplantation, Department of Surgery,
3 Department of Population Health Sciences
University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
Compared with the rope-ladder (RL) technique, buttonhole cannulation (BHC) provides a higher level of patient comfort, easier needle placement and reduction in hematoma and aneurysms. Recent studies, however, have documented a higher risk of infection with the BHC technique.
To the best of our knowledge, AVF patency has not been studied in this population. We analyzed the association of BHC with primary patency and clinical outcomes in our center.
A total of 45 prevalent dialysis patients using BHC were compared with 38 patients using the RL technique over a median of 12 months (inter-quartile range: 4-27 months). We compared outcomes of primary unassisted patency, episodes of bacteremia, access blood flow (Qa), and quality of life (QoL) scores.
The two groups did not differ significantly in demographics except that diabetes was more common in those with BHC as compared to RL (69% vs. 34%; p=0.002). The 3-month primary patency was 89.5% and 85.8% in the BHC and RL groups, respectively. The 12-month primary patency was 59.8% and 56.6% respectively. Risk factors associated with diminished primary patency were age (hazards ratio [HR]=1.19 per decade; 95% CI: 1.01-1.39; p=0.03) and female gender (HR=2.01; 95% CI: 1.13-3.58; p=0.02). Having BHC was not significantly associated with primary patency (HR=1.22, 95% CI: 0.65-2.28). Episodes of bacteremia (n=8; p=0.62), mean Qa before intervention (n=39; p=0.42) and after intervention (n=42; p=0.19) did not differ between BHC or RL technique. The presence of diabetes did not modify the association between BHC and patency (p=0.59). Furthermore, the physical and mental component, burden and symptoms scores from KDQOL health-related QoL were not different between groups (all p>0.05).
This study shows for the first time that there is no clear association between BHC use and access patency. Despite previous evidence on higher rates of bacteremia and better overall patient satisfaction, we found no significant differences in these clinical outcomes. Given the impending increase in home dialysis, quotidian therapies and emphasis on patient satisfaction, the role of BHC on access patency requires further study.
AVF by Nephrologist - Indian Experience
Balasubramaniam Jeyaraj, MD, DM
Kidney Care Centre, Tamil Nadu, India
Driving forces for interventions by a Nephrologist varies from centre to centre depending on geographical location of the centre and availability of co-specialists. In developing countries medical facilities are centered around cities and trained personnel are too few. Difficulty in scheduling with other departments, queue for OT time and space are driving forces in bigger established centres. Presently AV Fistula (AVF) is being created by various specialty people – Urologist, Vascular surgeon, Cardio thoracic surgeon, General surgeon, when in fact no one is specifically trained.
Aim: To study the feasibility and results of AVF creation by Nephrologist Methods: Study the results and complications of AVF created by Nephrologist at Kidney Care Centre from 2000 to 2010 and compare the results with those by the Surgeon Results:
Demographics: Surgeon Vs Nephrologist
Total Patients 626 1900
M/F(%) 72/28 76/24
Age-range 7-74 12-71
Age-mean 42 48
Side & Site: Surgeon Vs Nephrologist p values
L/R 65/35 80/20 ns
snuff/wrist/elbow 0/82/18 15/80/5 Less than 0.05
end to side/side to side 08/92 18/82 Less than 0.05
Time-mts 60 75 ns
Function:(%) 96 94 ns
Waiting -days 4 1 Less than 0.05
Hospital – stay 3 1.5 Less than 0.05
Bleeding 3 5 ns
Infection 3 4 ns
Sec h'ge 1 1 ns
Fistula thumb 5 0 Less than 0.05
This study has shown that AVF by Nephrologist is feasible with more distal site fistulas, shorter waiting period, shorter hospital stay, with comparable functioning and complications.
Conclusions: AVF by Nephrologist is a necessity in developing countries. AVF by Nephrologist is feasible and comparable to that of surgeon.
Surgical Management of Cephalic Arch Occlusive Lesions: Are There Predictors for Outcomes?
Shouwen Wang, MD, PhD¹, Ammar Almehmi, MD, MPH2 and Arif Asif, MD, FASN3
¹AKDHC-ASC, Arizona Kidney Disease and Hypertension Center, Phoenix, Arizona
2University Vascular Access Center, University of Tennessee College of Medicine, Memphis, Tennessee
3Division of Nephrology and Hypertension, Albany Medical College, Albany, New York
Background: Cephalic arch lesions arecommon cause for dysfunction of brachiocephalic arteriovenous fistulas. For lesions that were resistant or not amenable to endovascular interventions, we here used a term “cephalic arch occlusive lesions” (CAO). CAO lesions included: cephalic arch total occlusion, frequently recurrent stenosis (requiring angioplasty in <3-month intervals), high-grade elastic stenosis (residual stenosis >50% after angioplasty) or other lesions that were not amenable to endovascular interventions. Although various surgical revisions have been employed to manage CAO, scarce literature is available reporting their outcomes.
Methods: This series included 40 hemodialysis patients who underwent surgical revisions for dysfunctional fistulas due to CAO.
Results: The indications for surgical revisions were: total occlusions (17/40), frequently recurrent stenosis (17/40), high-grade elastic stenosis (5/40) and localized tortuous stenosis not amenable to endovascular intervention (1/40). The surgical procedures included: cephalic transposition and venovenostomy (CTV=37/40), basilic transposition and venovenostomy (1/40), stenotic segment resection (1/40) and cephalic-jugular vein bypass graft insertion (1/40). At 12-month post-CTV, the fistula primary, assisted primary and secondary patency rates were 25%, 82% and 97%, respectively. Pre-CTV angioplasty of the proximal cephalic vein (the segment distal to the cephalic arch that was used for transposition later) was the only siginificant predictor for the low primary patency rate (hazard ratio 4.5, P=0.002). Accordingly, the primary patency rates post-surgical revisions were 12% and 58% in patients with and without pre-CTV angioplasty of the proximal cephalic vein, respectively. Importantly, in a subgroup of 14 patients with recurrent cephalic arch stenosis and >12 months of follow-up post-revision, CTV reduced the number of angioplasties/year for cephalic lesions from 4.2±1.4 pre-CTV to 1.3±1.4 post-CTV (p<0.001).
Conclusions: Surgical interventions are effective in salvaging fistulas complicated by CAO. The current study finds that surgical interventions can provide excellent assisted primary and secondary patency rates and reduce the need for future endovascular interventions. Additionally, pre-CTV angioplasty of the proximal cephalic vein might adversely affect the outcome of CTV. We suggest that surgical interventions are effective treatment strategy for CAO.
1st Place Poster Winner
Fibrinous Hemodialysis Catheter Sheaths are Present Independent of Dysfunction and Their Disruption Improves Success of Guidewire Exchanges for Catheter-Associated Bacteremia
Adina Voiculescu, MD and Dirk Hentschel, MD
Brigham and Women’s Hospital, Boston, Massachusetts
Background: Catheter dysfunction and infections are leading causes for exchange of tunneled hemodialysis catheters. Fibrinous sheaths (FS) are commonly found during exchange of dysfunctional catheters. It is not known if sheaths are sufficient or necessary factors in catheter dysfunction or if their disruption is beneficial to prevent recurrence of catheter associated bacteremia.
Methods: We performed a retrospective analysis of all catheter exchanges performed from January 2008 to December 2011 with follow-up until May 2012, death or removal of the catheter. Central venography was performed before and after sheath disrupted.
Results: 183 catheters were exchanged in 98 patients. Main indications for catheter exchanges were dysfunction in 97 (53%), infection (CAB) in 42 (23%), and cuff exposure, dislodgement or malposition in 31 (17%). Fibrinous sheath were present in 93% (139 of 150) of all catheters and 88% (57 of 65) of catheters exchanged for reasons other than dysfunction. 95% (40 of 42) catheters exchanged for CAB had FS. There was no recurrent infection after catheter exchange with sheath disruption, isolates included: MSSA/MRSA 7, Enterococcus 7, Candida 2, gram negatives 7, and coag neg Staph 16. There was no difference of left or right-sided insertion regarding presence of sheath or frequency of infections. 46 patients (25%) had central vein stenoses at the time of exchange or during follow-up. Complications were one covered central vein extravasation prior to angioplasty and one stroke within 48 hours of an exchange.
Conclusions: Fibrinous sheaths are present in almost all dysfunctional as well as well-functioning tunneled hemodialysis catheters. Mechanisms that lead a “stable” sheath to occlude a given catheter await elucidation. - Recurrent infections after catheter exchanges over guidewire with disruption of fibrinous sheaths for treatment of catheter-associated bacteremia were not observed. This strategy lends itself for validation in a RCT.
2nd Place Poster Winner
Percutaneous AVG Creation in a Canine Model
Alexander Yevzlin, MD, Cindy Setum, PhD, and Michael Kallok, PhD
University of Wisconsin, Madison, Wisconsin
AVF and AVG creation in the US hemodialysis population is attended by lengthy delays due to multiple process of care issues, including operating room delays, anesthesia testing and clearance, and referral options. Moreover, most AVF and AVG require a period of time to mature that often requires an interval of catheter use. The purpose of the present experiment was to solve the latter problems by creating a completely percutaneous AVG. We hypothesized that a subcutaneous AVG can be created in a canine model to sustain flow at 3 hrs post. Further, we hypothesized that percutaneous intervention can be performed on the device safely. A 25 kg dog was anaesthetized and prepped in the usual non-sterile fashion. Heparin 50 u/kg was administered to the animal. Using percutaneous techniques and two novel anastomotic connectors for the venous and arterial anastomoses, a standard AVG was tunneled under the skin of the animal and was used to connect the femoral artery and femoral vein. Angiography immediately post intervention revealed patent flow from the femoral artery to the femoral vein of the animal at a BP of 65/35 mm Hg. Percutaneous intervention was then performed with a 5x40mm angioplasty balloon on the arterial and venous anastomosis without difficulty. The angiogram was repeated at 3.5 hour post implantation and revealed patent brisk flow through the AVG. This study shows for the first time that a percutaneous AVG can be created and flow can be sustained at 3+ hours post intervention. Given the importance of using any and all interventional strategies to decrease catheter use, a chronic animal study to test the ability to cannulate this type of AVG for 6 weeks is planned for 2013.
3rd Place Poster Winner
Renal Angiogram/Angioplasty-It’s Time Nephrologists Enter Cath Lab!
Balasubramaniam Jeyaraj, MD, DM
Kidney Care Centre, Tamil Nadu, India
BASIS: Management of Renal Artery Stenosis (RAS) continues to be a controversial subject even today. Unresolved issues are–which is the ideal diagnostic test, whether to treat RAS at all, if so when to treat and which modality(open surgery vs balloon angioplasty vs stenting) to use. Much more basic question yet to be answered is, who should be treating RAS-Cardiologist, Interventional radiologist, Vascular surgeon or the Nephrologist?
AIM: To study if decisions regarding diagnosis and treatment of RAS would be easier and optimal if Nephrologists themselves take over the whole management including USG/Doppler exam, Renal angiogram(RAG)and Angioplasties?
METHODS: All cases of Renal Angiograms done in Galaxy Hospitals, Tirunelveli were taken for the study. Patients who underwent renal angiogram were divided into three groups for comparison. Group 1:Those who underwent RAG before 2008 when cathlab facility became available at Galaxy Hospitals. Group 2:Those RAG's done by Nephrologist Group 3:Those RAG's done by Cardiologist and others. Nephrologist was involved in renal USG/Doppler study, RAG/angioplasty in the cathlab for all his cases. The incidence of RAS, the number of RAS intervened, type of intervention, complications and outcome were compared.
DISCUSSION: It is true that, CT angiogram and MR angiogram being contraindicated in patients with low GFR, definitive diagnosis of RAS has become very difficult. This could be the cause of under diagnosis of RAS. The judicious use of cathlab RAG, by the Nephrologist using minimal contrast (11ml),keeping contrast risks in mind, resulted in high strike rate of significant RAS 53 out of 177 (30%). This led to the significant increase in RAS from 9 to 53 after the involvement of the Nephrologist in USG/Doppler and the cathlab in Galaxy Hospitals. The prior knowledge of the full clinical picture enabled the Nephrologist to critically select patients for interventions, resulting in interventions only in 28 out of 53 RAS.
CONCLUSIONS: Advent of cathlab in a center and the involvement of Nephrologist in Renal USG/Doppler and RAG would 1. Increase the diagnostic rate of RAS. 2. Restrict intervention to ideal and deserving cases only. 3. Restrict Over and inappropriate treatment by others. 4. Help to accumulate data over time to give the right and just roll of interventions for RAS.
Inadvertent Great Vessel Arterial Catheterization During Ultrasound Guided Central Venous Line Placement-A Potentially Fatal Event.
Lakshmikumar Pillai, MD
West Virginia University Medical Center, Morgantown, West Virginia
OBJECTIVES: To review the incidence, efficacy of treatment, and outcome of inadvertent subclavian and carotid artery catheterization (with arterial catheter placement) during central venous access procedures which required open vascular and/or endovascular repair.
METHODS: 5-year retrospective review of all central venous access procedures performed at a teaching hospital.
RESULTS: From 2005-10 a total of 10,731 central venous access procedures were performed. There were 132 (1%) pneumo and/or hemo/pneumothoracies related to line placement. In 8 patients there was inadvertent/unrecognized subclavian or carotid artery catheterization requiring open and/or endovascular repair. All 8 procedures were done under “ultrasound guidance” by either Anesthesia or Critical Care Physicians attempting jugular line placement in the OR or ICU. Eighty-eight percent (7/8) were successfully repaired. 5 vessels (71%) were repaired using endovascular methods and 2 vessels (29%) using open surgery. The remaining injured vessel did not require repair due to successful treatment of hemothorax with chest tube resulting in hemostasis at site of vessel injury. However, 38% (3/8) of the patients still subsequently expired including the one patient whose vessel did not require repair – the other two deaths occurred in the patients who had undergone open repair of artery injury (1 subclavian/ 1 carotid). All deaths were related to the initial injury.
CONCLUSIONS: Though rare, inadvertent arterial catheterization during central line placement appears to be a highly morbid and fatal event in 38% of the patients in this study. Endovascular repair of these injuries appears to have better outcome. Although ultrasound guidance is the preferred method of jugular venous imaging during central vein catheterization, in this review it did not prevent inadvertent arterial catheterization and may indeed have imparted a false sense of security.
CAPD catheter insertion performed by Nephrologist - Indian Experience
Krishnaswamy Sampathkumar (Meenakshi Mission Hospital )
Background, Aims and Objectives:
Percutaneous CAPD catheter insertion performed by Nephrologist at the Interventional Nephrology Suite has many advantages including timing,wound healing,early start and economics.We describe our experience over a 6 year period performed by a single Nephrologist.
We Analysed 6 year data of the technique including,
a) the Demographics of the patients taken up for percutaneous technique
b) Complications - Infectious and Non infectious
c) Break in period
Materials and Methods:
Consecutive Patients giving informed consent to the procedure were taken up.We excluded abdomens with multiple scars and obese patients with BMI above 30.
The technique involves use of Stiff PD catheter with Stylet to pierce the rectus sheath into the peritoneal cavity . Placement is confirmed by dye injection under fluroscopy.This is followed by infusion of One Litre of Dialysate fluid. Insertion of guidewire is followed by peel away sheeth insertion and Precurved tenchoff catheter. The inner and outer cuffs are placed following usual guidelines.
Period :Jan 2006 to Feb 2012:total no of Patients=139:Male=88;Female=51;Age= 55.172+/- 12.0004 yrs. Wt= 57.762 +/- 10.399 Kg .Comorbidities : DM=102;HTN=123;IHD=47;OBESITY=2;Peripheral vascular disease =1.Type of catheter: Swan neck =132;Coiled=7.Complications: Catheter migration=2;Immediate Migration=1;Bowel Penetration=1;Bladder Penetration=2;Hernia=2;Omentum Wrapping=3;Exit site Reposition=1
Break in period: 7+2 days
Peritonitis rate: 1 in 40 patient months
Percutaneously inserted CAPD catheters by Nephrologist is highly successful in improving CAPD penetration in India.The complication rates are minimal and within internationally accepted limits.The technique should be popularised through hands on work shops as being done by the Authors.
FISTULAS FIRST, GRAFTS EQUALLY GOOD, CATHETERS APLENTY!
Peter Van, Renu Gupta and Neville R. Dossabhoy
Nephrology Section, LSUHSC and VA Medical Center, Shreveport, LA
The Fistula First Breakthrough Initiative has increased the placement of arteriovenous fistulae (AVF) for vascular access. The purpose of this study was to compare the overall survival of transposed brachial-basilic fistulae (TBBF), non-transposed (NT) AVF and AV Grafts (AVG) placed in the upper extremity (UE) in the era of Fistula First.
Our prospective, computerized clinical database was queried retrospectively to identify the outcomes of all upper extremity fistulae and grafts placed at our center over a 6-year period (2005-10). The primary end point was failure of the access. Kaplan-Meier curves were plotted for comparison of survival. 268 UE accesses were placed: 93 were TBBF, 139 were NT AVF, and 36 were AVG. The figure shows that there was no difference in the Kaplan-Meier survival curves for the three groups (P=0.37).
In conclusion, overall survival was similar for TBBF, NT AVF and AV grafts in our study, even with primary failures excluded (P=0.45). This study confirms that both types of fistulae have a high primary failure rate.
In the era of Fistula First, these findings question the wisdom of pushing fistula placement indiscriminately in all ESRD patients. In our previous study, we had noted that 29% of prevalent patients were using Permcaths. Hence, though prevalent utilization of AVF’s has increased to 55%, it seems to be at the cost of AVG’s (16%), not at the cost of Permcaths! Increasing utilization of AV Grafts in appropriate situations may help reduce catheter prevalence.