LAUSR

OBJECTIVE Society guidelines for permanent hemodialysis (HD) access creation recommend prioritizing the most distal possible autogenous access in order to minimize complications and preserve more proximal options. The "snuffbox" arteriovenous fistula (AVF) is the most distal radial-cephalic AVF. Despite the theoretical benefits of the snuffbox approach, recent trends have been toward upper arm accesses. Our study sought to investigate the feasibility of a snuffbox-first strategy for hemodialysis access in all anatomically appropriate candidates. METHODS Between January 2016 and August 2019, all patients with end stage renal disease (ESRD) or pre-ESRD under consideration for HD access were evaluated for a snuffbox-first approach by a team of vascular surgeons and nephrologists at a single, urban academic medical center in the United States. Data were collected prospectively and supplemented by chart review. Survival analysis was performed to evaluate primary unassisted and secondary patency, as well as clinical and functional maturation. Patients were censored if they received a kidney transplant or died. Cox Proportional Hazards regression determined risk factors for prolonged clinical maturation and functional maturation. RESULTS A total of 55 snuffbox AVFs were created. The median age was 60 years (IQR 52-70); 52.7% were male. Median follow-up was 369 days (IQR 166-509). Median survival for primary unassisted patency was 90 days (95% CI 79-111). Secondary patency at one year was 92.3% (95% CI 85.3-99.9%). Clinical maturation at one year was 83.7% (n=55, 95% CI 66.8-91.9%) and functional maturation at one year was 85.6% (n=40, 95% CI 63.3-94.4%). Of patients who were pre-ESRD at time of AVF creation and initiated hemodialysis during the study period, 87.5% successfully received incident hemodialysis with their snuffbox AVF. Twenty-four patients were receiving hemodialysis via a catheter at the time of snuffbox creation, and among those patients, functional maturation at 1 year was 82.5% (95% CI 44.8-94.4%). Patients underwent a median of 2 (IQR 2, range 0-7) interventions in the first year; 46.9% were percutaneous angioplasties, 31.2% were side-branch ligations. Diabetes was associated with slower AVF clinical maturation (multivariate HR 0.35, 95% CI 0.15-0.82, P=.016). Larger artery diameter was associated with earlier AVF clinical maturation (multivariate HR 6.64, 95% CI 2.11-20.9). CONCLUSIONS A snuffbox-first approach to hemodialysis access is a viable option for distal access creation in a cohort of hemodialysis patients in the United States. Subsequent ancillary interventions to facilitate access maturation were required in the majority of patients.