Vascular Access Surgery Timing: A Prospective European Cohort Study in Elderly Patients with ESKD

Background:
Timing vascular access creation for older patients with end-stage kidney disease (ESKD) is challenging. Autologous arteriovenous fistulas (AVF) are often created too early, leading to unused fistulas, or too late, necessitating central venous catheters (CVC). This study reports on vascular access creation in relation to hemodialysis initiation in European practice.

Methods:
This study is a secondary analysis of the EQUAL cohort: a prospective observational study that recruited patients aged ≥65 years with stage 4 or 5 chronic kidney disease from six European countries. Patients were selected once their eGFR dropped below 15 ml/min/1.73m², if they received a vascular access, and had at least six months of follow-up. Vascular access timing was categorized into three groups: early (no dialysis within six months after AVF creation), on time (dialysis initiated with an AVF within six months), and late (hemodialysis initiated with a CVC before or within six months after AVF creation).

Results:
A total of 332 patients from the EQUAL cohort were analysed: 221 patients (67%) received an AVF as first vascular access and 111 patients (33%) a CVC. Among the latter, 53 patients (48%) underwent subsequent AVF creation, whereas for the remaining 58 patients, CVC was considered the intended vascular access strategy. At dialysis initiation, 158 patients (54%) used an AVF, while 136 patients (46%) used a CVC. AVF creation was on time in 88 of 274 patients (32%), early in 114 patients (42%), and late in 72 patients (26%). Despite high rates of early AVF creation, most fistulas were eventually used, as 90% of patients initiated hemodialysis within three years.

Conclusion:
Only 32% of elderly ESKD patients started hemodialysis with a functional AVF created on time (within the six-month window), while 42% had early and 26% late creation. Clinical prediction tools are needed to optimize vascular access timing.