Perforating vein fistula is superior to forearm fistula in elderly haemodialysis patients with diabetes and arterial hypertension

Background. Access-related problems are one of the major causes of morbidity in elderly patients with chronic kidney disease. The aim of this study was to assess potential risks and benefits in elderly patients comparing forearm arteriovenous fistula (AVF) and perforating vein AVF below the elbow for primary vascular access. Methods. A retrospective comparison of elderly patients (65.7 6 9.3 years, 70.4% male patients, 36.2% late referral) undergoing primary vascular access surgery using forearm AVF (n ¼ 50) and perforating vein AVF (n ¼ 55) was performed over a 2-year period, including a multivariate analysis of potential risk factors and benefits of primary patency (PP ¼ intervention-free access survival) and secondary patency (SP ¼ access survival until abandonment). Results. Patency rates after 24 months were significantly higher in patients with perforating vein AVF (PP 1 SP: 78.2%) compared to forearm AVF (PP: 62%, SP: 56%, P ¼ 0.04). Presence of diabetes mellitus in patients with forearm AVF was associated with a decreased PP [odds ratio (OR): 3.6, 95% confidence interval (CI): 0.9–13.8] and SP (OR: 4.8, 95% CI: 1.3–17.9), and arterial hypertension was associated with a lower PP (OR: 6.7, 95% CI: 0.8–53.9), whereas the presence of hyperparathyroidism was associated with higher PP and SP (OR: 0.2, 95% CI: 0.1–0.7). In contrast, PP and SP in patients with perforating vein AVF were not influenced by comorbidities. Conclusions. Perforating vein AVF is superior to forearm AVF in elderly patients with diabetes and arterial hypertension due to the proximal fistula location, probably caused by an improved artery distensibility during fistula maturation.