Management of infected arteriovenous grafts for haemodialysis: Outcomes and strategies using a novel objective scoring system

Abstract

Background: In haemodialysis patients with exhausted autogenous options, prosthetic arteriovenous grafts (AVGs) are frequently utilised as tertiary vascular access. However, the prosthetic nature of AVGs precipitates an increased risk of infection which may translate to excess morbidity and life-threatening complications. The current evidence remains divided on the optimal treatment strategy for arteriovenous graft infections (AVGi) with arguments for conservative management by antibiotics, salvaging with graft revision or total/subtotal excision. To address this gap, we assessed the outcomes of AVGi patients treated in our institution, developing an AVGi severity classification model and a proposed treatment algorithm to guide AVGi management. Methods: We conducted a single centre retrospective review of outcomes of patients with AVGi managed either by sole antibiotics therapy, graft revision or surgical excision between June 2016 and May 2021. Outcomes of AVGi patients across differing treatment groups were compared, including 1-year mortality, 6-month and 1-year functional vascular access. We also analysed the outcomes of tunnelled haemodialysis lines (THL), which were used as a temporary vascular access in several AVGi patients in our study. Results: A total of 34 AVGi patients were managed within that time frame and included in the study (5 conservatively management by antibiotics, 5 graft revisions and 24 surgical excision) with a mean age of 60.4 ± 14.4 years (67.6% males). Overall 1-year mortality was 14.7%. A 6-month functional vascular access status across the three groups stood at 60%, 60% and 10% while 1-year functional vascular access status was 60%, 75% and 42% respectively. Conclusions: When clinically appropriate, conservative management by antibiotics or salvage/graft revision can present as prudent AVGi treatment options. The adoption of our proposed severity classification system and treatment algorithm provides a more thorough objective assessment of the infection and helps guide the clinical decision-making process.