Regional anesthesia for AV fistula creation confers superior outcomes, leads to cost-savings
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Using regional anesthesia for patients undergoing arteriovenous fistula creation for dialysis access conferred better patency outcomes at 1 year compared with local anesthesia, according to a recently published study.
These results build on previous findings that showed regional anesthesia also improves primary AVF patency in the short-term.
“Regional anesthesia (RA), such as brachial plexus block, involves targeted injection of local anesthetic (LA) to block motor and sensory nerves supplying the operative site,” Emma Aitken, PhD, of Queen Elizabeth University Hospital in Glasgow, United Kingdom, and colleagues wrote. “Unlike LA infiltration for AVF creation, RA also blocks sympathetic nerves resulting in vasodilation, improved blood flow and reduced vasospasm both perioperatively and in the early postoperative period. Until recently, there was no evidence that short-term perioperative hemodynamic changes secondary to anesthesia could improve longer-term fistula patency.”
They added that because, “long-term functional patency is the ultimate goal of vascular access surgery,” they expanded the time-frame of their previous study (3 months) to 1 year.
Investigators randomly assigned 126 patients undergoing primary radiocephalic or brachiocephalic AVF creation to receive regional anesthesia (brachial plexus block; 0.5% L-bupivacaine and 1.5% lidocaine with epinephrine) or local anesthesia (0.5% L-bupivacaine and 1% lidocaine).
At 12 months, the researchers observed both higher primary patency and higher functional patency among patients receiving regional vs. local anesthesia (79% vs. 59% and 68% vs. 49%, respectively).
Regional anesthesia also resulted in net savings of 195.10 British pounds (US, $237.36) per patient at 1 year, and an incremental cost-effectiveness ratio of approximately 12,900 British pounds (US, $15,694.20) per quality-adjusted life years over 5 years.
Aitken and colleagues acknowledged that the study is reflective of practice in the United Kingdom and, thus, the results may not be directly applicable to the United States where there is a larger proportion of patients with obesity and diabetes. In addition to these “factors known to be associated with adverse AVF outcomes,” CMS encourages freedom from tunneled dialysis catheter by 90 days, and rates of secondary AVF interventions have been estimated to be as high as 44%, according to the researchers. In contrast, they wrote, only 11% of patients in this study had an intervention to assist maturation, and none were within the first 90 days.
Still, Aitken and colleagues highlighted the utility of the findings, which demonstrate both clinical benefit and evidence of cost-effectiveness
“These results confirm an enduring superiority of RA over LA in achieving primary and functional AVF patency at 12 months and are, to our knowledge, the first randomized data to demonstrate an anesthetic technique improving any long-term surgical outcome,” they concluded.
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