BACKGROUND: The arteriovenous access stage (AVAS) classification provides evaluation of upper extremity vessels for vascular access (VA) suitability. It divides patients into classes within three main groups: suitable for native fistula (AVAS1) or prosthetic graft (AVAS2), and patients not suitable for conventional native or prosthetic VA (AVAS3). We validated this system on a prospective dataset. METHODS: A prospective, international observational study (NCT04796558) involved 11 centres from 8 countries. Patient recruitment was from March 2021 to January 2024. Demographic data, risk factors, vessels parameters, VA types, AVAS class and early VA failure were collected. Percentage agreement was used to assess predictive ability of AVAS (comparison of AVAS and created VA) and consistency of AVAS assessment between evaluators. Pearson's Chi-squared test was used for comparison of early failure rate of conventional (predicted by AVAS) and unconventional (not predicted by AVAS) VA. RESULTS: From 1034 enrolled patients, 935 had arteriovenous fistula or graft, 99 patients did not undergo VA creation due opting for alternative renal replacement therapies, experiencing health complications, death or non-compliance. AVAS1 had 91.2%, AVAS2 7.2% and AVAS3 1.6% of patients. Agreement between evaluators was 89%. The most frequently created VAs were radial-cephalic (46%) and brachial-cephalic (27%) fistulae. The accuracy of AVAS versus created access was 79%. In comparison, VA predicted by clinicians versus created access was 62.1%. Inaccuracy of AVAS prediction was more common with higher AVAS classes, and the most common reason for inaccuracy was creation of distal VA despite less favourable anatomy (17%). Patients with unconventional VA had higher early failure rate than patients with conventional VA (20% vs 9.3%, respectively, P = .002). CONCLUSION: AVAS is effective in predicting VA creation, but overall accuracy is reduced at higher AVAS classes when the complexity of decision-making increases and proximal vessels require preservation. When AVAS was followed by clinicians, early failure was significantly decreased.

3rd Faculty of Medicine Charles University Prague Prague Czech Republic

AdNa s r o Vascular Surgery Clinic Košice Slovakia

Cardiocenter University Hospital Královské Vinohrady 3rd Faculty of Medicine Charles University Prague Czech Republic

Centre for Medical Education Queen's University Belfast Belfast UK

Centre for Vascular and Mini invasive Surgery Hospital AGEL Třinec Podlesí Czech Republic

Department of Anaesthesiology and Resuscitation University Hospital Královské Vinohrady Prague Czech Republic

Department of General Surgery Hospital Professor Doutor Fernando Fonseca Amadora Portugal

Department of Nephrology and Transplantation Medicine Wroclaw Medical University Wroclaw Poland

Department of Physiology Faculty of Medicine Masaryk University Brno Czech Republic

Department of Renal Surgery Queen Elizabeth University Hospital Glasgow UK

Department of Transplant Surgery and Regional Nephrology Unit Belfast City Hospital Belfast UK

Department of Transplantation Surgery Institute for Clinical and Experimental Medicine Prague Czech Republic

Department of Vascular Surgery National Institute for Cardiovascular Disease Bratislava Slovakia

Division of Nephrology and Haemodialysis Internal Medicine Department University Hospital of Split Split Croatia

Division of Vascular and Endovascular Surgery Cardio Thoracic Vascular Department University Hospital of Trieste Trieste Italy

Division of Vascular Surgery University Hospital Královské Vinohrady Prague Czech Republic

Nephrology and Dialysis Unit Department of Medicine ASUGI University Hospital of Trieste Trieste Italy

RL Vascular Surgery and Interventional Radiology Private Practice Salvador Brazil

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Lok  CE, Huber  TS, Lee  T  et al.  KDOQI clinical practice guideline for vascular access: 2019 update. Am J Kidney Dis  2020;75:S1–164. 10.1053/j.ajkd.2019.12.001 PubMed DOI

Beathard  GA, Jennings  WC, Wasse  H  et al.  Integrated vascular access management. Blood Purif  2003;21:89–98. 10.1159/000067858 PubMed DOI

Konner  K, Nonnast-Daniel  B, Ritz  E. The arteriovenous fistula. J Am Soc Nephrol  2003;14:1669–80. 10.1097/01.ASN.0000069219.88168.39 PubMed DOI

Schmidli  J, Widmer  MK, Basile  C  et al.  Editor's choice—vascular access: 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg  2018;55:757–818. 10.1016/j.ejvs.2018.02.001 PubMed DOI

Chlorogiannis  DD, Bousi  SE, Zachiotis  M  et al.  Pre-operative ultrasound mapping before arteriovenous fistula formation: an updated systematic review and meta-analysis. J Nephrol  2023;37:281–92. 10.1007/s40620-023-01814-6 PubMed DOI PMC

Canaud  B, Ponce  P, Parisotto  MT  et al.  Vascular access management for haemodialysis: a value-based approach from NephroCare experience. In: Berezin  AE (ed.) Vascular Access Surgery—Tips and Tricks, Vol. 1. London, England: IntechOpen, 2019, 1–37.

Tordoir  J, Canaud  B, Haage  P  et al.  EBPG on Vascular Access. Nephrol Dial Transplant  2007;22:ii88–117. 10.1093/ndt/gfm021 PubMed DOI

Baláž  P, Hanko  J, Magowan  H  et al.  The arteriovenous access stage (AVAS) classification. Clin Kidney J  2021;14:1747–51. 10.1093/ckj/sfaa189 PubMed DOI PMC

Sidawy  AN, Gray  R, Besarab  A  et al.  Recommended standards for reports dealing with arteriovenous hemodialysis accesses. J Vasc Surg  2002;35:603–10. 10.1067/mva.2002.122025 PubMed DOI

Harika  G, Mallios  A, Allouache  M  et al.  Comparison of surgical versus percutaneously created arteriovenous hemodialysis fistulas. J Vasc Surg  2021;74:209–16. 10.1016/j.jvs.2020.12.086 PubMed DOI

Hull  JE, Jennings  WC, Cooper  RI  et al.  The pivotal multicenter trial of ultrasound-guided percutaneous arteriovenous fistula creation for hemodialysis access. J Vasc Interv Radiol  2018;29:149–58.e5. 10.1016/j.jvir.2017.10.015 PubMed DOI

Franco  G, Mallios  A, Bourquelot  P  et al.  Ultrasound evaluation of percutaneously created arteriovenous fistulae between radial artery and perforating vein at the elbow. J Vasc Access  2020;21:694–700. 10.1177/1129729819897654 PubMed DOI PMC

Katerina  L, Stephen  O, Petr  W  et al.  VAVASC study: clinical trial protocol. J Vasc Access  2023;24:792–7. PubMed

Tordoir  JHM, Keuter, X, Planken  N  et al.  Autogenous options in secondary and tertiary access for haemodialysis. Eur J Vasc Endovasc Surg  2006;31:661–6. PubMed

Padberg  FT Jr, Calligaro  KD, Sidawy  AN. Complications of arteriovenous hemodialysis access: recognition and management. J Vasc Surg  2008;48(5 Suppl):55S–80S. PubMed

Perl  J, Wald  R, Mcfarlane  P  et al.  Hemodialysis vascular access modifies the association between dialysis modality and survival. J Am Soc Nephrol  2011;22:1113–21. PubMed PMC

Polkinghorne  KR, Mcdonald  SP, Atkins  RC  et al.  Vascular access and all-cause mortality: a propensity score analysis. J Am Soc Nephrol  2004;15:477–86. PubMed

Goodkin  DA, Pisoni  RL, Locatelli  F  et al.  Hemodialysis vascular access training and practices are key to improved access outcomes. Am J Kidney Dis  2010;56:1032–42. 10.1053/j.ajkd.2010.08.010 PubMed DOI

Saran  R, Elder  SJ, Goodkin  DA  et al.  Enhanced training in vascular access creation predicts arteriovenous fistula placement and patency in hemodialysis patients: results from the Dialysis Outcomes and Practice Patterns Study. Ann Surg  2008;247:885–91. 10.1097/SLA.0b013e31816c4044 PubMed DOI

Lawrie  K, Bafrnec  J, O'Neill  S  et al.  Identifying classification systems regarding vascular access for haemodialysis: protocol for a scoping review. BMJ Open  2022;12:e064842. 10.1136/bmjopen-2022-064842 PubMed DOI PMC

Wilmink  T. Elbow arteriovenous fistulae. J Vasc Access  2014;15:50–4. 10.5301/jva.5000237 PubMed DOI

Al Shakarchi  J, Nath  J, McGrogan  D  et al.  End-stage vascular access failure: can we define and can we classify?  Clin Kidney J  2015;8:590–3. 10.1093/ckj/sfv055 PubMed DOI PMC

Shahverdyan  R, Konner  K, Segerer  S  et al.  Novel classification of proximal forearm perforator vein in the planning and creation of percutaneous and surgical Gracz-type arteriovenous fistulae. J Vasc Access  2022;25:872–82. 10.1177/11297298221141480 PubMed DOI

Lauvao  LS, Ihnat  DM, Goshima  KR  et al.  Vein diameter is the major predictor of fistula maturation. J Vasc Surg  2009;49:1499–504. 10.1016/j.jvs.2009.02.018 PubMed DOI

Dageforde  LA, Harms  KA, Feurer  ID. Increased minimum vein diameter on preoperative mapping with duplex ultrasound is associated with arteriovenous fi stula maturation and secondary patency. J Vasc Surg  2015;61:170–6. 10.1016/j.jvs.2014.06.092 PubMed DOI

Gilmore  J. KDOQI clinical practice guidelines and clinical practice recommendations–2006 updates. Nephrol Nurs J  2006;33:487–8. PubMed

Ravani  P, Palmer  SC, Oliver  MJ  et al.  Associations between hemodialysis access type and clinical outcomes: a systematic review. J Am Soc Nephrol  2013;24:465–73. 10.1681/ASN.2012070643 PubMed DOI PMC

Oliver  MJ, McCann  R, Indridason  O  et al.  Comparison of transposed brachiobasilic fistulas to upper arm grafts and brachiocephalic fistulas. Kidney Int  2001;60:1532–9. 10.1046/j.1523-1755.2001.00956.x PubMed DOI

Machine learning validation of the AVAS classification compared to ultrasound mapping in a multicentre study