J Vasc Surg. 2026 Jun 10:S0741-5214(26)00863-3. doi: 10.1016/j.jvs.2026.04.007. Online ahead of print.
ABSTRACT
OBJECTIVE: Peripheral arterial disease (PAD) is highly prevalent among patients requiring hemodialysis access and reflects advanced systemic atherosclerosis. We evaluated whether PAD severity is associated with increased postoperative complications and loss of primary patency following dialysis access creation and performed stratified analyses by access type: arteriovenous fistula (AVF) and arteriovenous graft (AVG).
METHODS: We used the Vascular Quality Initiative database from 2011 to 2024, including patients undergoing upper-extremity hemodialysis access creation. PAD status was categorized as no PAD, asymptomatic PAD, claudication, or chronic limb-threatening ischemia (CLTI). Postoperative outcomes included 30-day mortality, prolonged length of stay, bleeding, thrombosis, and steal syndrome. Six-month primary patency was defined as time to first intervention, thrombosis, failure, or abandonment. Multivariable logistic and Cox regression analyses were performed in the overall cohort, followed by subgroup analyses stratified by AVF and AVG.
RESULTS: A total of 78,607 patients were included (25,718 [32.7%] no PAD; 47,771 [60.8%] asymptomatic PAD; 2079 [2.6%] claudication; and 3039 [3.9%] CLTI). In the overall cohort, increasing PAD severity was independently associated with worse postoperative outcomes. Compared with patients without PAD, asymptomatic PAD (adjusted odds ratio [aOR] 1.55; 95% confidence interval [CI], 1.27-1.90; P < .001), claudication (aOR 2.20; 95% CI, 1.52-3.18; P < .001), and CLTI (aOR 3.01; 95% CI, 2.24-4.06; P < .001) were associated with progressively higher odds of 30-day mortality. Asymptomatic PAD (aOR 1.41; 95% CI, 1.16-1.71; P < .001) and CLTI (aOR 2.27; 95% CI, 1.82-2.83; P < .001) were associated with prolonged length of stay. Asymptomatic PAD was also associated with increased odds of postoperative bleeding (aOR 1.30; 95% CI, 1.01-1.69; P = .043). Claudication (aOR 3.57; 95% CI, 1.33-9.59; P = .012) and CLTI (aOR 2.87; 95% CI, 1.21-6.82; P = .017) were associated with increased odds of steal syndrome, whereas PAD severity was not associated with postoperative thrombosis. At 6 months, all PAD stages were strongly associated with loss of primary patency: asymptomatic PAD (adjusted hazard ratio [aHR] 5.09; 95% CI, 3.15-8.22; P < .001), claudication (aHR 4.79; 95% CI, 2.86-8.02; P < .001), and CLTI (aHR 5.05; 95% CI, 3.14-8.10; P < .001). Findings were consistent in analyses stratified by AVF and AVG.
CONCLUSIONS: To our knowledge, this is the first study to comprehensively evaluate the impact of PAD and PAD progression on outcomes and patency of dialysis access. PAD severity is independently associated with increased postoperative complications, 30-day mortality, and loss of primary patency following dialysis access creation. Notably, even asymptomatic PAD confers significantly increased risk of mortality and loss of primary patency at 6 months. These findings highlight the importance of incorporating PAD status into preoperative risk stratification and dialysis access planning.
PMID:42268171 | DOI:10.1016/j.jvs.2026.04.007