Clinical Outcomes of Patients Ineligible for Arteriovenous Vascular Access: A Retrospective Cohort Analysis

BACKGROUND: A subset of patients with advanced chronic kidney disease (CKD) or kidney replacement therapy becomes ineligible for arteriovenous vascular access creation due to vascular exhaustion or comorbidity-driven contraindications. Outcomes following a negative surgical vascular access recommendation remain poorly characterized and may differ according to kidney replacement therapy status at assessment. METHODS: We retrospectively studied all patients evaluated by a multidisciplinary vascular access team (January 2022-December 2024) who received a negative surgical recommendation for autologous or prosthetic vascular access construction. Patients were primarily stratified as pre-dialysis CKD G4-5 or already receiving kidney replacement therapy. Reason for ineligibility was analyzed descriptively. RESULTS: Among 647 patients evaluated, 40 (6.2%) patients received a negative surgical vascular access recommendation; 20 were pre-dialysis CKD G4-5 and 20 were already receiving kidney replacement therapy. Vascular exhaustion accounted for 23 cases and comorbidity-driven contraindication for 17. Among pre-dialysis patients, 11/20 (55%) initiated kidney replacement therapy after index evaluation: 10 initiated hemodialysis and 1 initiated peritoneal dialysis. Non-planned hemodialysis initiation occurred in 9/10 (90%) patients who started hemodialysis as their first kidney replacement therapy modality, mainly due to acute cardiorenal or coronary syndromes. Among patients already receiving kidney replacement therapy, surgical ineligibility identified persistent absence of durable arteriovenous options: 18/20 (90%) received hemodialysis after index evaluation, with prolonged catheter exposure. Overall, 17/40 (43%) patients died, including 7/20 (35%) pre-dialysis patients and 10/20 (50%) already-kidney replacement therapy patients. CONCLUSIONS: Surgical vascular access ineligibility defines a high-risk clinical state whose implications differ by kidney replacement therapy status. Earlier identification, structured modality assessment, and timely palliative integration may better align care with prognosis, physiology, and patient goals.