Arteriovenous Fistula Has the Lowest Thrombosis and Infection Rates
The arteriovenous fistula (AVF) is definitively the hemodialysis access with both the lowest thrombosis rate and lowest infection rate, making it superior to arteriovenous grafts and central venous catheters on both measures. 1, 2
Infection Rate Comparison
The hierarchy of infection risk is clear and unequivocal:
- AVF has infection rates of only 1-4% over its entire use-life 1, 2, representing the lowest infection risk of all access types
- AVG has infection rates of 11-20% over its use-life 1, 2, approximately 3-5 times higher than AVF
- Tunneled catheters have bacteremia rates of 5% at 3 months but 50% removal due to infection at 1 year 2, with systemic infection targets of <10% at 3 months and <50% at 1 year 1
- Non-tunneled catheters have infection rates of 2.7 per 1,000 catheter-days versus 1.6 for tunneled catheters 2, with <8% incidence at 2 weeks that increases exponentially with time 1, 2
The relative risk of bacteremia with AVF is 7 times lower than with catheters 2, and real-world data confirms infection rates dropping from 6.6% to 0.6% when programs successfully transition patients from catheters to AVF 3.
Thrombosis Rate Comparison
The thrombosis advantage of AVF is equally compelling:
- AVF thrombosis rate should be <0.25 episodes per patient-year at risk (after excluding initial failures within first 2 months) 1
- AVG thrombosis rate target is <0.5 episodes per patient-year at risk 1, representing double the AVF rate
- AVF has 3-7 times fewer complication events than prosthetic grafts 2
Clinical studies demonstrate thrombosis occurring in only 9.0% of fistulae versus 24.7% of grafts 4, and access clotting rates dropping from 5.1% to 1.0% when AVF rates increase 3.
Clinical Impact on Morbidity and Mortality
The superiority of AVF translates directly to patient outcomes:
- Infections related to vascular access are a primary cause of morbidity and mortality in dialysis patients 1, 2
- AVF is associated with lower mortality and hospitalization compared to other access types 2
- Programs increasing AVF use from 35% to 82% demonstrate hospitalization rates dropping from 6.1% to 3.8% 3
- Chronic catheter access is associated with lower blood flow rates, compromised dialysis adequacy, and increased risk of central venous stenosis 1, all of which increase morbidity and mortality
Why AVF Outperforms Other Access Types
The biological advantages are fundamental:
- AVF uses autogenous tissue without foreign material, eliminating the substrate for bacterial colonization that plagues grafts and catheters 1, 2
- Native vessel endothelium resists thrombosis more effectively than synthetic graft material 1
- Absence of external exit sites (as with catheters) eliminates a major portal of entry for pathogens 1, 2
Common Pitfall to Avoid
Do not assume all access types are equivalent - the evidence unequivocally establishes AVF superiority for both thrombosis and infection outcomes 1, 2. The 2019 KDOQI guidelines explicitly recommend AVF as preferred access when clinical circumstances are favorable, specifically due to fewer long-term vascular access events including thrombosis 1. While AVG may have equivalent long-term patency in some studies 4, this does not negate the dramatic differences in infection and thrombosis rates that directly impact patient morbidity and mortality.
Answer: A. Arteriovenous fistula