Although forearm arteriovenous fistulas (AVFs) are the preferred initial vascular access for hemodialysis based on national guidelines, there are no population-level studies evaluating trends in creation of forearm vs upper arm AVFs and arteriovenous grafts (AVGs). The purpose of this study was to report temporal trends in first-time permanent hemodialysis access type, and to assess the effect of national initiatives on rates of AVF placement. Retrospective cross-sectional study (2012-2022) utilizing the Vascular Quality Initiative database. All patients older than 18 years with creation of first-time upper extremity surgical hemodialysis access were included. Anatomic location of the AVF or AVG (forearm vs upper arm) was defined based on inflow artery, outflow vein, and presumed cannulation zone. Primary analysis examined temporal trends in rates of forearm vs upper arm AVFs and AVGs using time series analyses (modified Mann-Kendall test). Subgroup analyses examined rates of access configuration stratified by age, sex, race, dialysis, and socioeconomic status. Interrupted time series analysis was performed to assess the effect of the 2015 Fistula First Catheter Last initiative on rates of AVFs. Of the 52,170 accesses, 57.9% were upper arm AVFs, 25.2% were forearm AVFs, 15.4% were upper arm AVGs, and 1.5% were forearm AVGs. From 2012 to 2022, there was no significant change in overall rates of forearm or upper arm AVFs. There was a numerical increase in upper arm AVGs (13.9 to 18.2 per 100; = .09), whereas forearm AVGs significantly declined (1.8 to 0.7 per 100; = .02). In subgroup analyses, we observed a decrease in forearm AVFs among men (33.1 to 28.7 per 100; = .04) and disadvantaged (Area Deprivation Index percentile ≥50) patients (29.0 to 20.7 per 100; = .04), whereas female (17.2 to 23.1 per 100; = .03), Black (15.6 to 24.5 per 100; < .01), elderly (age ≥80 years) (18.7 to 32.5 per 100; < .01), and disadvantaged (13.6 to 20.5 per 100; < .01) patients had a significant increase in upper arm AVGs. The Fistula First Catheter Last initiative had no effect on the rate of AVF placement (83.2 to 83.7 per 100; =.37). Despite national initiatives to promote autogenous vascular access, the rates of first-time AVFs have remained relatively constant, with forearm AVFs only representing one-quarter of all permanent surgical accesses. Furthermore, elderly, Black, female, and disadvantaged patients saw an increase in upper arm AVGs. Further efforts to elucidate factors associated with forearm AVF placement, as well as potential physician, center, and regional variation is warranted.

中文翻译：

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瘘管第一时代建立血液透析通路的时间趋势

尽管根据国家指南，前臂动静脉瘘 (AVF) 是血液透析的首选初始血管通路，但没有人群水平的研究评估前臂与上臂 AVF 和动静脉移植物 (AVG) 的创建趋势。本研究的目的是报告首次永久性血液透析通路类型的时间趋势，并评估国家举措对 AVF 安置率的影响。利用血管质量倡议数据库进行回顾性横断面研究（2012-2022）。所有年龄超过 18 岁且首次建立上肢手术血液透析通路的患者均被纳入。 AVF 或 AVG（前臂与上臂）的解剖位置是根据流入动脉、流出静脉和假定的插管区域来定义的。主要分析使用时间序列分析（改良的曼-肯德尔检验）检查前臂与上臂 AVF 和 AVG 比率的时间趋势。亚组分析检查了按年龄、性别、种族、透析和社会经济地位分层的接入配置率。我们进行了间断时间序列分析，以评估 2015 年瘘管首导管末计划对 AVF 发生率的影响。在 52,170 次访问中，57.9% 为上臂 AVF，25.2% 为前臂 AVF，15.4% 为上臂 AVG，1.5% 为前臂 AVG。从 2012 年到 2022 年，前臂或上臂 AVF 的总体发生率没有显着变化。上臂 AVG 数值有所增加（每 100 人 13.9 至 18.2；= .09），而前臂 AVG 显着下降（每 100 人 1.8 至 0.7；= .02）。在亚组分析中，我们观察到男性（每 100 人 33.1 至 28.7 个；= .04）和弱势群体（面积剥夺指数百分位数≥50）患者（每 100 人 29.0 至 20.7；= .04）的前臂 AVF 有所减少，而女性（每 100 人 17.2 至 23.1；= .03）、黑人（每 100 人 15.6 至 24.5；< .01）、老年人（每 100 人 18.7 至 32.5；< .01）和弱势群体（每 100 人 13.6 至 20.5） 100；< .01) 患者上臂 AVG 显着增加。瘘管第一导管最后举措对 AVF 置入率没有影响（每 100 例 83.2 至 83.7；=.37）。尽管国家采取了促进自体血管通路的举措，但首次 AVF 的发生率仍然相对稳定，前臂 AVF 仅占所有永久性手术通路的四分之一。此外，老年人、黑人、女性和弱势患者的上臂 AVG 有所增加。有必要进一步努力阐明与前臂 AVF 放置相关的因素，以及潜在的医生、中心和区域差异。