IFT02 - Impact of Peripheral Arterial Disease Diagnosis and Progression on Outcomes of Dialysis Access Surgery

Objectives: Nearly 20% of patients on hemodialysis have a history of lower extremity peripheral arterial disease (PAD). Despite being a systemic disease affecting the whole body’s vasculature, there is limited evidence regarding the impact of PAD and its progression on outcomes following upper extremity arteriovenous fistula (AVF) creation for dialysis access.

Methods: The Vascular Quality Initiative was queried from July 2011 to December 2024 for patients who underwent dialysis access creation procedures. We excluded patients with arteriovenous grafts or any fistula created in the lower extremity. Patients were stratified into four groups according to PAD history and stage: non-PAD, asymptomatic (documented PAD without ischemic pain), claudication, chronic limb threatening ischemia (CLTI: rest pain or tissue loss). Early postoperative outcomes include 30-day mortality, prolonged length of stay >1 day (PLOS), bleeding, and thrombosis. Patency at 6 months, defined as time from access creation to the first intervention, thrombosis, failure, or abandonment, was also analyzed. Adjusted logistic regression analyzed postoperative outcomes, while multivariable Cox regression, Kaplan Meier survival analysis and Log Rank test analyzed 6-month patency.

Results: A total of 61,103 AVFs were included: non-PAD 19,753(32.3%), asymptomatic 37,593(61.5%), claudication 1,536(2.5%), CLTI 2,221(3.7%). Non-PAD patients were more likely to be receiving local/regional anesthesia and were non-smokers. Claudicants were the oldest, more likely to have hypertension, CAD, and CHF. CLTI patients were more likely to be male, diabetic and obese. After adjusting to confounders, asymptomatic patients had 52% higher risk of 30-day mortality [aOR=1.52(1.23-1.88),p < 0.001] compared to patients without PAD; while claudicants had double [aOR=2.35(1.52-3.63),p < 0.001] and CLTI patients had triple the risk [aOR=3.11(2.07-4.69),p < 0.001] (Table I). Asymptomatic group was associated with 36% increased odds of PLOS [aOR=1.36(1.09-1.71),p=0.007] while the risk in the CLTI group was more than double [aOR=2.28(1.78-2.92),p < 0.001] compared to non-PAD. History of PAD regardless of the stage had more than 4-fold increased hazard of loss of patency at 6 months(Fig-1). There was no significant difference in bleeding or thrombosis among the groups(p>0.05).

Conclusions: To our knowledge this is the first study to comprehensively evaluate the impact of PAD on outcomes and patency of AVFs. Our findings demonstrate that PAD, even in its asymptomatic stages, negatively impacts the outcomes of patients undergoing dialysis access procedures. Our findings emphasize the importance of considering PAD in risk stratification and optimizing medical management in these patients. Further studies are needed to understand the negative impact of PAD on the durability of hemodialysis access and ways to improve it.