Arteriovenous Fistula (AVF) Has the Lowest Rates of Thrombosis and Infection
The arteriovenous fistula (AVF) is the hemodialysis access with the lowest rates of both thrombosis and infection, making it the preferred first-line access for hemodialysis patients. 1, 2
Infection Risk by Access Type
The hierarchy of infection risk from lowest to highest is clearly established:
- AVF: 1-4% infection rate over the lifetime of the access, with a relative risk of bacteremia 7 times lower than catheters 2, 3
- Arteriovenous grafts (AVG): 11-20% infection rate during their expected usage period 2
- Tunneled catheters: 50% removal rate due to infection at 1 year, with bacteremia rate of 1.6 per 1,000 catheter-days 2
- Non-tunneled catheters: Highest risk, with infection incidence increasing exponentially over time 2
Clinical studies confirm AVF infection rates as low as 0.9% compared to 9.5% for grafts 4, and implementation of AVF-first programs has reduced infection rates from 6.6% to 0.6% 5.
Thrombosis Risk by Access Type
AVF demonstrates superior thrombosis resistance:
- AVF thrombosis rate: 9.0% in clinical practice 4
- AVG thrombosis rate: 24.7% - nearly triple the AVF rate 4
- Polytetrafluoroethylene (PTFE) grafts carry 1.98 times higher thrombosis risk compared to AVF (95% CI = 1.3.01) 6
The probability of remaining thrombosis-free at 90 days after first use is 90.1% for AVF versus only 71.6% for PTFE grafts 6. Programs implementing AVF-first strategies have reduced vascular access clotting from 5.1% to 1.0% 5.
Order of Preference for Access Placement
The 2001 KDOQI guidelines establish the following hierarchy: 1
- Wrist (radial-cephalic) primary AVF - first choice due to simplicity, vessel preservation, and lowest complication rates
- Elbow (brachial-cephalic) primary AVF - second choice with higher flow rates
- Arteriovenous graft (PTFE) - only when AVF cannot be established
- Tunneled central venous catheter - discouraged as permanent access
This hierarchy is reinforced by the 2019 KDOQI paradigm shift emphasizing individualized patient life-planning while maintaining AVF preference 1, 7.
Clinical Outcomes and Quality of Life
AVF provides superior outcomes beyond infection and thrombosis rates:
- Lower mortality and hospitalization compared to all other access types 2, 3
- 3-7 times fewer complication events than prosthetic grafts 2
- Better dialysis adequacy with higher Kt/V and urea reduction ratios after 6 months compared to catheters 8
- Improved blood flow rates from 214 mL/min to 298 mL/min when transitioning from catheters to AVF 5
Implementation of AVF-first programs demonstrates reduced hospitalization rates from 6.1% to 3.8% and 19% reduction in erythropoietin requirements 5.
Critical Timing Considerations
AVF maturation time significantly impacts thrombosis risk:
- Maturation >30 days reduces thrombosis risk by 60% (RR 0.40; 95% CI = 0.14,0.84) 6
- Early referral to nephrology enables proper AVF planning and reduces emergency catheter placement 1
- Dialyzer blood flow rates >300 mL/min further reduce thrombosis risk (RR 0.66; 95% CI = 0.44,0.99) 6
Common Pitfalls to Avoid
Late referral remains the primary barrier - up to 73% of patients in some regions are hospitalized for dialysis initiation with temporary catheters due to inadequate access planning 1. This results in increased morbidity, mortality, and healthcare costs 1, 3.
Premature abandonment of AVF attempts - while AVF may have lower initial success rates due to maturation failure, their long-term patency and complication profiles far exceed alternatives once established 1, 3.
Subclavian vein catheterization should be avoided as it damages vessels needed for future AVF creation 1.