Debunking Fistula First: An In-depth Analysis of Operative Futility and Patient Outcomes
Authors: Neeli Devee Krishna Sashidhar , Gowda Suhas S , Desai Sanjay C , Ramswamy Chandrashekar Anagavalli 
Published: February 2025

Abstract

Introduction:
End-stage kidney disease (ESKD) represents a significant healthcare challenge affecting millions globally. Patients with ESKD require renal replacement therapy, with hemodialysis being a common modality. Various strategies for vascular access include arteriovenous fistulas (AVFs), arteriovenous (AV) grafts, and tunneled dialysis catheters. In 2003, the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative guidelines supported the “Fistula First” initiative as AVFs last longer, have lower infection rates, and result in fewer complications. However, the one-size-fits-all approach did not account for individual patient differences, particularly in those with significant comorbidities or poor vascular anatomy. It also failed to address the unique needs of patients who might be more suitable for other types of access, such as AV grafts or tunneled dialysis catheters, especially those with poor clinical prognoses. Clinical experience and retrospective studies have revealed that a substantial proportion of AVFs fail to mature or maintain patency, leading to additional procedures and increased patient burden. In addition, the Fistula First initiative’s focus on AVFs sometimes resulted in premature or unnecessary surgeries for patients not yet requiring dialysis, contributing to operative futility. Due to these limitations, there has been a shift from the “Fistula First” initiative to the “ESKD Life-Plan” approach. This study aims to assess the outcomes of autogenous AVFs in terms of operative futility (not matured, never dialyzed through fistula, early ligation secondary to fistula-induced limb ischemia, early secondary patency failure, and mortality).

Objectives:
The objectives of this study were to study the postoperative outcomes, maturation, and complications after surgical creation of AVF.

Materials and Methods:
This is a single-center, retrospective study done for 6 months from November 2023 to April 2024, where 150 patients who underwent AVFs were included in the study. Demographics, operative futility, and outcomes were collected and analyzed from medical records.

Results and Conclusions:
Out of 150 fistulas, 73% were brachiocephalic fistulas, and 27% were radiocephalic fistulas. The mean age of presentation was 53 years, with a male preponderance (82%). Most of the patients had type II diabetes mellitus (57%) and systemic hypertension (93%). Ninety percent of patients were on hemodialysis before AVF creation. Within 6 weeks of AVF creation, 29 patients had intensive care unit admissions, and 18 patients suffered mortality. One patient had neuropraxia postcreation. Five patients underwent tributary ligation, and two patients underwent access angioplasty but did not mature. Six percent (nine patients) of fistulas matured but were never accessed. None of the patients had AVF-induced limb ischemia. Twenty-four percent of fistulas never matured for hemodialysis. The maturation rate was higher in brachiocephalic fistulas (65%) compared to radiocephalic fistulas (51%). Overall, according to our study, 60% of the fistulas matured to functionality for hemodialysis. Hence, this high rate of operative futility suggests the risks of prioritizing patient treatment based on technique rather than individual patient factors, supporting the “ESKD Life-Plan” strategy over the “Fistula First” initiative.