Improved maturation of two-stage over single-stage basilic vein transposition for first-time hemodialysis access creation: A multilevel model

Successful brachiobasilic arteriovenous fistula (BBAVF) creation can be performed in single or two stages, with evidence supporting either approach. Although surgeon and practice pattern often influence surgical approach, little is known about the role of practice patterns in maturation and reintervention-free fistula survival. We conducted a retrospective study using the Vascular Quality Initiative from 2011 to 2022, including patients undergoing BBAVF procedures for first-time hemodialysis access with at least 4 weeks of follow-up. The primary outcome was fistula maturation. Our analysis incorporated a multilevel model, clustering by surgeon effects. Secondary analysis examined 1-year freedom from the composite outcome of access reintervention, fistula abandonment, or death, using Cox proportional hazards modeling and Kaplan-Meier survival analysis. Likelihood ratio testing was used to analyze model fit. Among 6417 patients, 1347 (21%) underwent single-stage and 5043 (79%) underwent two-stage BBAVF creation. Overall maturation was 60.6%. On univariable analysis, two-stage fistulas had higher maturation (62.3% vs 54.3%, P < .001) and 1-year reintervention-free fistula survival (50.5% vs 47.9%, P = .008). Multilevel adjusted analysis demonstrated that two-stage procedures were associated with higher maturation rates (odds ratio: 1.4, 95% confidence interval: 1.1-1.6, P = .001) and lower 1-year composite reintervention, abandonment, or death risk (hazard ratio: 0.88, 95% confidence interval: 0.8-0.98, P = .018). Clustering by surgeon random effects significantly improved model fit for maturation rate (likelihood ratio: 66.9, P < .001) and 1-year reintervention, abandonment, or death (likelihood ratio: 4774.7, P < .001). Two-stage BBAVF creation was associated with superior maturation and 1-year reintervention-free fistula survival, even after adjusting for surgeon practice patterns. With other patient factors equal, a two-stage approach should be considered for first-time BBAVF creation.