Comparison of one-stage and two-stage upper arm brachiobasilic arteriovenous fistula in the Vascular Quality Initiative

Objective: An upper arm brachiobasilic arteriovenous fistula (BBAVF) is a reliable autogenous hemodialysis access created with a one-stage or two-stage technique. Although both techniques are variably used, the optimal approach is uncertain. In this study, we compared the outcomes of one-stage and two-stage BBAVF procedures. Methods: We identified 2648 patients who had received BBAVFs within the Vascular Quality Initiative data set (2010-2016) and compared those created using the one-stage and two-stage technique. The primary outcome measures were primary and secondary patency rates at 12 months. Other outcomes assessed were wound infection, steal, and swelling at 3 months. The log-rank test was used to evaluate patency by Kaplan-Meier analysis. Cox proportional hazards models were used to examine the adjusted association between surgical technique and outcomes. Results: There were 1234 (47%) one-stage and 1414 (53%) two-stage BBAVFs in the study cohort, including 1848 (70%) patients who were on dialysis at the time of surgery and 1795 (68%) patients with a history of previous access. Patients who underwent a one-stage BBAVF were more likely to be male (54% vs 45%; P <.001), to be white (60% vs 41%; P <.001), and to have a history of coronary artery disease (22% vs 17%; P =.001). Patients undergoing one-stage BBAVFs have larger vein diameters (4.1 vs 3.4 mm; P <.001) and have the procedure in an inpatient setting (21% vs 13%; P <.001) compared with patients undergoing a two-stage procedure. The 12-month primary patency rate was higher for the one-stage BBAVF (49.1% vs 40.4%; P =.005), although the secondary patency rate was comparable (80.0% vs 77.9%; P =.54). Postoperative bleeding (4% vs 1.5%; P <.001), wound infection (1.01% vs 0.4%; P =.047), and arm swelling (2.1 % vs 0.8%; P =.006) were higher for one-stage BBAVFs. In multivariable analysis, although loss of primary patency at 12 months (adjusted hazard ratio [aHR], 1.12; 95% confidence interval [CI], 0.97-1.30; P =.12) and 3-month wound infection (aHR, 0.42; 95% CI, 0.14-1.25, P =.12) were similar between the two approaches, the risk of 3-month arm swelling was significantly lower for two-stage BBAVFs (aHR, 0.35; 95% CI, 0.16-0.77; P =.009). Conclusions: Whereas surgeons were more likely to perform a two-stage BBAVF in patients with a history of previously failed access and smaller basilic vein, our data show no difference in primary or secondary patency of one-stage and two-stage BBAVFs at 12 months.