Synthetic vascular hemodialysis access versus native arteriovenous fistula: a cost-utility analysis

Ann Surg. 2012 Jan;255(1):181-6. doi: 10.1097/SLA.0b013e31822f4e9b.


Objective: To determine the cost-effectiveness of 2 different vascular access strategies among incident dialysis patients.

Background: Vascular access is a principal cause of morbidity and cost in hemodialysis patients. Recent guidelines and initiatives are intended to increase the proportion of patients with a fistula. However, there is growing awareness of the high prevalence of fistula failures and attendant complications.

Methods: A decision analysis using a Markov model was implemented to compare 2 different vascular access strategies among incident dialysis patients: (1) placing an arteriovenous fistula (AVF1st) as the initial access followed by a synthetic vascular access if the AVF did not mature compared to (2) placing a synthetic vascular access (SVA1st) as the initial access device. The cost-utility was evaluated across a range of the risk of complications from temporary catheters and SVA.

Results: Under base case assumptions, the AVF1st strategy yielded 2.19 quality-adjusted life years (QALYs) compared with 2.06 QALYs from the SVA1st strategy. The incremental cost-effectiveness was $9389 per QALY for AVF1st compared to SVA1st and was less than $50,000 per QALY as long as the probability of maturation is 36% or greater. AVF1st was the dominant strategy when the AVF maturation rate was 69% or greater.

Conclusion: The high risk of complications of temporary catheters and the overall low AVF maturation rate explain why a universal policy of AVF1st for all incident dialysis patients may not optimize clinical outcomes. Strong consideration should be given to a more patient-centered approach taking into account the likelihood of AVF maturation.

Publication types

  • Comparative Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Arteriovenous Shunt, Surgical / economics*
  • Arteriovenous Shunt, Surgical / mortality
  • Catheters, Indwelling / economics*
  • Cost-Benefit Analysis
  • Decision Support Techniques
  • Graft Occlusion, Vascular / economics
  • Graft Occlusion, Vascular / mortality
  • Graft Occlusion, Vascular / surgery
  • Health Care Costs / statistics & numerical data
  • Humans
  • Kidney Failure, Chronic / economics*
  • Kidney Failure, Chronic / mortality
  • Kidney Failure, Chronic / therapy*
  • Male
  • Markov Chains
  • Medicaid / economics
  • Medicare / economics
  • Middle Aged
  • Polytetrafluoroethylene*
  • Quality-Adjusted Life Years
  • Renal Dialysis / economics*
  • Renal Dialysis / mortality
  • Reoperation / economics
  • Survival Rate
  • United States


  • Polytetrafluoroethylene