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Background: Hemodialysis (HD) dependence and autogenous fistula use for HD span the spectrum of age. This study examines age-related outcomes of autogenous fistulas for HD access in a large population-based cohort of patients., Methods: A retrospective cohort study of all patients who initiated HD in the United States Renal Database System (2007-2014). χ 2 tests, t tests, Kaplan-Meier, log-rank tests, multivariable logistic, and Cox regression analyses were employed to evaluate access maturation, interventions, patency, and mortality., Results: Of the 303,281 patients studied, 48,892 (16.1%) were younger than 50 years, 55,817 (18.4%) were 50 to 59 years, 79,138 (26.1%) were 60 to 69 years, 75,200 (24.8%) were 70 to 79 years, and 44,234 (14.6%) were 80 years or older. There was a decrease in autogenous fistula maturation with increasing age. Primary patency at 5 years comparing patients <50 vs 50 to 59 vs 60 to 69 vs 70 to 79 vs 80+ years was 24% vs 23% vs 21% vs 20% vs 18% (P < .001). Primary assisted patency at 5 years was 38% vs 40% vs 37% vs 35% vs 33% (P < .001). Secondary patency at 5 years was 48% vs 50% vs 47% vs 45% vs 42% (P < .001). The risk-adjusted analyses revealed a progressive decrease in primary, primary assisted, and secondary patency with increasing age. As expected, patient survival decreased with increasing age., Conclusions: In this population-based cohort of HD patients, there was a decrease in autogenous fistula maturation, primary patency, primary assisted patency, secondary patency, and patient survival with increasing age. Despite the relative decline in outcomes associated with older age, decisions about arteriovenous access creation in older patients should be individualized, taking overall clinical status and outcomes of alternatives modes of access into consideration., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: This study evaluated the effect of diabetes on outcomes of autogenous fistulas and prosthetic grafts for hemodialysis access in a large population-based cohort of patients., Methods: A retrospective cohort study was conducted of all patients who initiated hemodialysis in the United States Renal Database System (2007-2014). The χ 2 test, Student t-test, Kaplan-Meier analysis, log-rank test, and multivariable logistic and Cox regression analyses were employed to evaluate maturation, interventions, patency, infection, and mortality., Results: The study of 381,622 patients comprised 303,307 (79.5%) autogenous fistulas and 78,315 (20.5%) prosthetic grafts placed in 231,134 (60.6%) diabetic patients and 150,488 (39.4%) nondiabetic patients. There was decrease in maturation for diabetics compared to nondiabetics who received autogenous fistulas (adjusted hazard ratio [aHR], 0.86; 95% confidence interval [CI], 0.83-0.88; P < .001) and prosthetic grafts (aHR, 0.88; 95% CI, 0.83-0.93; P < .001). Comparing diabetics vs nondiabetics, primary patency at 5 years was 19.4% vs 23.5% (P < .001) for autogenous fistulas and 9.1% vs 11.2% (P < .001) for prosthetic grafts. Primary assisted patency at 5 years was 35.2% vs 38.7% (P < .001) for autogenous fistulas and 17.2% vs 19.2% (P = .015) for prosthetic grafts. Secondary patency at 5 years was 44.8% vs 48.6% (P < .001) for autogenous fistulas and 34.1% vs 36.8% (P = .002) for prosthetic grafts. There was 5% decrease in primary patency (aHR, 0.95; 95% CI, 0.94-0.96; P < .001) for diabetics compared to nondiabetics who received autogenous fistulas. There was no difference in primary assisted and secondary patency for autogenous fistulas as well as primary, primary assisted, and secondary patency for prosthetic grafts in comparing diabetic to nondiabetic patients. There was also no significant difference in severe prosthetic graft infection between the groups (aHR, 0.99; 95% CI, 0.92-1.08; P = .90). There was a 19% increase in patient mortality for diabetic relative to nondiabetic autogenous fistula recipients (aHR, 1.19; 95% CI, 1.17-1.20; P < .001) and 12% increase for prosthetic graft recipients (aHR, 1.12; 95% CI, 1.10-1.15; P < .001)., Conclusions: In this population-based cohort of hemodialysis patients, diabetes mellitus was associated with a decrease in patient survival, access maturation, and primary fistula patency. In contrast, there was no association between diabetes and prosthetic graft patency and severe prosthetic graft infection warranting excision., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The prevalence of end-stage renal disease spans the spectrum of age. Arteriovenous grafts are viable alternatives for hemodialysis access in patients whose anatomy precludes placement of an arteriovenous fistula. This report describes the age-related outcomes after arteriovenous graft placement in a population-based cohort., Methods: A retrospective cohort study was conducted of all patients who initiated hemodialysis in the U.S. Renal Data System (2007-2014). The χ 2 test, t-test, Kaplan-Meier analysis, log-rank test, and multivariable logistic and Cox regression analyses were employed to evaluate access maturation, interventions, patency, and mortality., Results: Of the 78,341 patients studied, 10,150 (13%) were younger than 50 years, 13,167 (16.8%) were 50 to 59 years, 19,975 (25.5%) were 60 to 69 years, 20,307 (25.9%) were 70 to 79 years, and 14,742 (18.8%) were 80+ years. There was no significant difference in access maturation time for patients in the older age categories compared to patients younger than 50 years. Primary patency at 5 years comparing <50 years vs 50 to 59 years vs 60 to 69 years vs 70 to 79 years vs 80+ years was 12% vs 12% vs 9% vs 9% vs 8% (P < .001). Primary assisted patency at 5 years was 20% vs 21% vs 18% vs 17% vs 14% (P < .001). Secondary patency at 5 years was 36% vs 39% vs 36% vs 30% vs 31% (P < .001). There was no significant difference in primary patency (adjusted hazard ratio [aHR], 1.00; 95% confidence interval [CI], 1.00-1.00; P < .001), primary assisted patency (aHR, 1.00; 95% CI, 1.00-1.00; P < .001), and secondary patency (aHR, 1.00; 95% CI, 1.00-1.00; P = .029) with increasing age. However, there was a decrease in severe prosthetic graft infection requiring graft excision (aHR, 0.99; 95% CI, 0.99-0.99; P < .001) and increase in mortality (aHR, 1.03; 95% CI, 1.03-1.03; P < .001) for the older age categories compared with the younger patients., Conclusions: In this population-based cohort of hemodialysis patients, there was no significant association between older age and prosthetic graft maturation or patency. However, older age was associated with a decrease in severe graft infection and the expected increase in mortality., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: There are limited data on the impact of carotid angioplasty and stenting (CAS)-related changes in blood pressure, heart rate, and preprocedural medications on periprocedural stroke in contemporary, real-world practice. This study evaluates the risk attributable to the CAS-related hemodynamic events and the impact preprocedural medications have on mitigating this risk in a large, population-based cohort., Methods: We studied all patients in the Vascular Quality Initiative who underwent CAS between January 2006 and December 2016. Kaplan-Meier, multivariable logistic, and Cox regression analyses were used to evaluate the impact of periprocedural hypertension, hypotension, bradycardia, and medication use on immediate periprocedural stroke (IPPS), 30-day, and 1-year stroke., Results: Of the 13,698 CAS procedures studied, 1239 (9.1%), 1824 (13.3%), and 1333 (9.7%) patients experienced periprocedural hypertension, hypotension, and bradycardia, respectively. IPPS was 3.2% vs 2.1% vs 0.65% (P < .001), comparing patients with periprocedural hypertension vs hypotension vs normotension and 1.4 vs 1.0% (P = .19) for bradycardic vs nonbradycardic patients. Periprocedural hypertension was associated with a four-fold increase in IPPS (adjusted odd ratio [aOR], 3.97; 95% confidence interval [CI], 2.63-5.99; P < .001). periprocedural hypotension and bradycardia were associated with 5.5-fold (aOR, 5.56; 95% CI, 3.24-9.52; P < .001) and 2.3-fold (aOR, 2.31; 95% CI, 1.26-4.25; P = .007) increases in IPPS among patients with carotid symptoms. There was 76% decrease in IPPS for patients who did not experience a periprocedural hemodynamic event (aOR, 0.24; 95% CI, 0.16-0.35; P < .001). Unlike preprocedural beta-blockers and angiotensin-converting enzyme inhibitors, prophylactic antibradyarrhythmic agents conferred a 58% reduction in IPPS among patients with carotid symptoms (aOR, 0.42; 95% CI, 0.23-0.78; P = .006). The periprocedural hemodynamic events were also associated with 7.7-fold increase in myocardial infarction (aOR, 7.70; 95% CI, 4.77-12.45; P < .001), a 2.2-fold increase in 30-day mortality (aOR, 2.24; 95% CI, 1.61-3.12; P < .001), and a 16% increase in length of stay (aOR, 1.16; 95% CI, 0.04-2.28; P = .042). The occurrence of these hemodynamic events is higher in patients with prior cardiac disease and the difference in periprocedural outcomes extended to 1 year., Conclusions: Periprocedural hemodynamic events are associated with an increase in periprocedural stroke, myocardial infarction, death, and length of stay. Periprocedural hypertension in all patients; hypotension and bradycardia in patients with symptomatic carotid disease are associated with significant increase in IPPS. Prophylactic antibradyarrhythmic agents are associated with decrease in bradycardia and IPPS. These results heighten the need to anticipate and promptly address these CAS-related hemodynamic events, especially in susceptible patients., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate patterns of use and outcomes of arteriovenous fistulas and prosthetic grafts within racial categories in a large population based cohort of hemodialysis (HD) patients in the United States., Methods: A retrospective analysis of white, black, and Hispanic patients in the prospectively maintained United States Renal Database System who had an autogenous fistula or prosthetic graft placed for HD access between January 2007 and December 2014 was performed. Analysis of variance, χ 2 , t-tests, Kaplan-Meier, log-rank tests, multivariable logistic, and Cox regression analyses were used to evaluate maturation, patency, infection, and mortality., Results: This study of 359,942 patients, composed of 285,781 autogenous fistulas (79.4%) and 74,161 prosthetic grafts (20.6%) placed in 213,877 white (59.4%), 115,727 black (32.2%), and 30,338 Hispanic (8.4%) patients. There was a 11% increase in the risk-adjusted odds of HD catheter use as bridge to autogenous fistula placement in blacks (adjusted odds ratio, 1.11; 95% confidence interval [CI], 1.08-1.14; P < .001) and a 9% increase in Hispanics (adjusted odds ratio, 1.09; 95% CI, 1.05-1.14; P < .001) compared with whites. Fistula maturation for HD access for whites vs blacks vs Hispanics was 77.0% vs 76.3% vs 77.8% (P = .35). After adjusting for covariates, fistula maturation was higher for blacks (adjusted hazard ratio, 1.09; 95% CI, 1.06-1.13; P < .001) and Hispanics (adjusted hazard ratio, 1.13; 95% CI, 1.06-1.20; P < .001) compared with whites. There was no significant difference in prosthetic graft maturation for blacks and Hispanics compared with whites. Primary, primary-assisted, and secondary patency were highest for Hispanic and least for black autogenous fistula recipients. Primary, primary-assisted, and secondary patency was also highest for Hispanic patients who received prosthetic grafts. Prosthetic grafts were associated with a decrease in patency and patient survival compared with fistulas in all racial categories. Mortality was lower for blacks and Hispanics relative to white patients. Initiation of HD with a catheter and conversion to autogenous fistula was associated with decrease in patency and patient survival compared with initiation with a fistula in all racial groups., Conclusions: Autogenous fistulas are associated with better patency and patient survival compared with prosthetic grafts for all races studied. The use of HD catheter before fistula placement is more prevalent in Hispanic and black patients and is associated with worse patency and patient survival irrespective of race. Fistula and graft patency is highest for Hispanic patients. Patient survival is higher for Hispanic and black patients relative to whites. These associations suggest potential benefit with initiation of HD via autogenous fistula and minimizing temporizing catheter use, irrespective of race., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to compare the outcomes of arteriovenous fistulas (AVFs) with arteriovenous grafts (AVGs) in a large population-based cohort of elderly patients in the United States., Methods: A retrospective analysis was performed of all patients ≥75 years old in the prospectively maintained United States Renal Database System who had an AVF or AVG placed for hemodialysis (HD) access between January 2007 and December 2011. Outcomes were mortality, conduit patency, maturation, time to catheter-free dialysis, and infection. A χ 2  test, Student t-test, Kaplan-Meier analysis, and multivariable Cox regression analysis were employed., Results: Of the 124,421 patients studied, there were 19,173 (15%) AVF initiates, 4480 (4%) AVG initiates, 29,872 (24%) AVF converts, 10,712 (9%) AVG converts, and 59,824 (48%) patients who persisted on HD catheters. Compared with AVF initiates, relative mortality was significantly higher for AVG initiates (adjusted hazard ratio [aHR], 1.24; P < .001), AVF converts (aHR, 1.36; P < .001), AVG converts (aHR, 1.62; P < .001), and catheter-persistent patients (aHR, 2.23; P < .001). Primary patency (aHR, 1.21; P < .001) and primary assisted patency (aHR, 1.31; P < .001) were higher for AVF. Secondary patency was higher for AVGs within the first 4 months (aHR, 1.12; P < .001) but higher for AVFs beyond that time point (aHR, 1.25; P < .001). Maturation rate and median time to maturation were 80% vs 84% (P < .001) and 46 vs 26 days (P < .001) for AVF vs AVG., Conclusions: Pre-emptive AVF remains the best mode of HD in elderly patients who can tolerate surgery. Patients who cannot tolerate pre-emptive surgery or have to initiate HD on an urgent basis with a catheter should convert to AVF when it is feasible if life expectancy is >4 months. If life expectancy is <4 months, surgical risk and quality of life should be considered in making the decision to persistently dialyze through HD catheter or to convert to AVG., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: This study examines the utilization and outcomes of vascular access for long-term hemodialysis in the United States and describes the impact of temporizing catheter use on outcomes. We aimed to evaluate the prevalence, patency, and associated patient survival for pre-emptively placed autogenous fistulas and prosthetic grafts; for autogenous fistulas and prosthetic grafts placed after a temporizing catheter; and for hemodialysis catheters that remained in use., Methods: We performed a retrospective study of all patients who initiated hemodialysis in the United States during a 5-year period (2007-2011). The United States Renal Data System-Medicare matched national database was used to compare outcomes after pre-emptive autogenous fistulas, preemptive prosthetic grafts, autogenous fistula after temporizing catheter, prosthetic graft after temporizing catheter, and persistent catheter use. Outcomes were primary patency, primary assisted patency, secondary patency, maturation, catheter-free dialysis, severe access infection, and mortality., Results: There were 73,884 (16%) patients who initiated hemodialysis with autogenous fistula, 16,533 (3%) who initiated hemodialysis with prosthetic grafts, 106,797 (22%) who temporized with hemodialysis catheter prior to autogenous fistula use, 32,890 (7%) who temporized with catheter prior to prosthetic graft use, and 246,822 (52%) patients who remained on the catheter. Maturation rate and median time to maturation were 79% vs 84% and 47 days vs 29 days for pre-emptively placed autogenous fistulas vs prosthetic grafts. Primary patency (adjusted hazard ratio [aHR], 1.26; 95% confidence interval [CI], 1.25-1.28; P < .001) and primary assisted patency (aHR, 1.36; 95% CI, 1.35-1.38; P < .001) were significantly higher for autogenous fistula compared with prosthetic grafts. Secondary patency was higher for autogenous fistulas beyond 2 months (aHR, 1.36; 95% CI, 1.32-1.40; P < .001). Severe infection (aHR, 9.6; 95% CI, 8.86-10.36; P < .001) and mortality (aHR, 1.29; 95% CI, 1.27-1.31; P < .001) were higher for prosthetic grafts compared with autogenous fistulas. Temporizing with a catheter was associated with a 51% increase in mortality (aHR, 1.51; 95% CI, 1.48-1.53; P < .001), 69% decrease in primary patency (aHR, 0.31; 95% CI, 0.31-0.32; P < .001), and 130% increase in severe infection (aHR, 2.3; 95% CI, 2.2-2.5; P < .001) compared to initiation with autogenous fistulas or prosthetic grafts. Mortality was 2.2 times higher for patients who remained on catheters compared to those who initiated hemodialysis with autogenous fistulas (aHR, 2.25; 95% CI, 2.21-2.28; P < .001)., Conclusions: Temporizing catheter use was associated with higher mortality, higher infection, and lower patency, thus undermining the highly prevalent approach of electively using catheters as a bridge to permanent access. Autogenous fistulas are associated with longer time to catheter-free dialysis but better patency, lower infection risk, and lower mortality compared with prosthetic grafts in the general population., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Little is known of the excess risk attributable to secondary carotid angioplasty and stenting (CAS). This study evaluates outcomes of redo-CAS and CAS after prior ipsilateral carotid endarterectomy (CASAPICEA) relative to primary-CAS., Methods: We studied all patients in the Vascular Quality Initiative, who underwent primary-CAS, CASAPICEA, or redo-CAS (2003-2016). Kaplan-Meier, multivariable logistic and Cox regression analyses were used to evaluate outcomes within 30 days and up to 1 year and identify their predictors., Results: There were 11 742 CAS procedures performed: 8519 (72%) primary-, 2645 (23%) CASAPICEA, and 578 (5%) redo-CAS. Comparing primary-CAS versus CASAPICEA versus redo-CAS, 30-day stroke/death was 2.5% versus 2.0% versus 1.3% for asymptomatic patients ( P =0.23) and 5.2% versus 2.6% versus 5.0% for symptomatic patients ( P =0.003). CASAPICEA was associated with significantly lower 30-day stroke/death (odds ratio: 0.60; 95% confidence interval: 0.37-0.98; P =0.04) compared with primary-CAS among symptomatic patients. The odds of bradycardia were lower following CASAPICEA (odds ratio: 0.32; 95% confidence interval: 0.26-0.39; P <0.001) and redo-CAS (odds ratio: 0.55; 95% confidence interval: 0.39-0.78; P =0.001) compared with primary-CAS. Similarly, the odds of hypotension were significantly lower in both groups compared with primary-CAS (CASAPICEA: 0.41 [0.35-0.48], P <0.001; redo-CAS: 0.66 [0.50-0.86] P =0.003). There were no significant differences in the hazards of stroke/death at 1 year for CASAPICEA and redo-CAS compared with primary-CAS., Conclusions: CASAPICEA is associated with significantly lower odds of periprocedural stroke/death compared with primary-CAS among symptomatic patients. CASAPICEA and redo-CAS are associated with significantly lower odds of periprocedural hypotension and bradycardia but higher odds of hypertension compared with primary-CAS., (© 2017 American Heart Association, Inc.)

Objective: In-stent restenosis is a recognized complication of carotid angioplasty and stenting (CAS), and it is associated with an increased risk of stroke. Few case series have reported outcomes separately following carotid endarterectomy (CEA) and CAS for the treatment of in-stent restenosis. In this study, we perform an evaluation of redo-CAS vs CEA in a large contemporary cohort of patients who underwent prior ipsilateral CAS., Methods: We studied all patients in the Vascular Quality Initiative (VQI) database, who underwent CEA or CAS between January 1, 2003, and April 30, 2016, after prior ipsilateral CAS. Univariate methods (χ 2 , t-test), Kaplan-Meier, logistic, and Cox regression analyses adjusting for patient characteristics were employed to evaluate stroke, death, myocardial infarction (MI), stroke/death, and stroke/death/MI within 30 days and up to 1 year following the procedure., Results: There were 645 carotid interventions (CEA, 134 [21%] and redo-CAS, 511 [79%]) performed in this cohort of patients with prior ipsilateral CAS. Postoperative stroke within 30 days comparing CEA vs CAS was 0% vs 0.3% (P = .61) for asymptomatic patients and 4.4% vs 3.5% (P = .79) for symptomatic patients for an overall stroke rate of 1.5% vs 1.4%. MI was 2.3% vs 1.2% (P = .35), 30-day mortality was 3.7% vs 0.9% (P = .02) following CEA vs CAS, whereas the composite of perioperative stroke/death was 4.5% vs 1.9% (P = .09). Freedom from stroke/death at 1 year was 91% for CEA and 92% for redo-CAS (P = .76). After risk adjustment, there was no significant difference in 30-day stroke (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.15-4.48; P = .82), mortality (OR, 2.21; 95% CI, 0.54-9.11; P = .27), or stroke/death (OR, 0.99; 95% CI, 0.26-3.84; P = .99) as well as 1-year stroke (hazard ratio [HR], 0.60; 95% CI, 0.13-2.85; P = .52), mortality (HR, 0.83; 95% CI, 0.42-1.65; P = .60), or stroke/death (HR, 0.80; 95% CI, 0.43-1.49; P = .48) comparing CEA with CAS. The significant predictors of perioperative stroke/death were older age, diabetes, active smoking, and preoperative American Society of Anesthesiologists class IV status (all P < .05)., Conclusions: We have reported adverse event rates for CEA and CAS after prior CAS and shown no significant difference in perioperative and 1-year outcomes between both groups. However, CEA is offered to patients who are more severely ill than redo-CAS, resulting in significantly higher absolute mortality. We recommend avoidance of CEA especially in asymptomatic patients with serious systemic disease. Tight management of diabetes and smoking cessation remain potent targets for outcomes improvement in redo-CAS patients., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Patients who require hemodialysis are historically excluded from randomized studies of carotid artery stenting (CAS) due to perceived poor outcomes. Observational studies of outcomes after CAS in hemodialysis patients are mostly limited to small, single-institution series., Objective: This study evaluated long-term outcomes after CAS in a large nationally representative cohort of hemodialysis patients., Methods: We studied all patients who underwent CAS in the United States Renal Disease System database between January 2006 and December 2011. Patient outcomes were determined by matching with the Medicare database. Univariable and multivariable logistic and Cox regression were used to compare perioperative (stroke, death, myocardial infarction) and long-term (stroke, death) outcomes after CAS., Results: The cohort included 1109 patients who underwent CAS. Median follow-up was 2.5 years (interquartile range, 1.30-3.71; maximum, 4.97 years). Mean age was 67 (standard deviation, 9.9) years, and 61% of patients were male, 75% were white, and 83% were asymptomatic. Overall, 30-day perioperative stroke, myocardial infarction, and death rates were 5.5%, 5.5%, and 3.1%, respectively. Long-term freedom from stroke was 90% at 1 year, 85% at 2 years, and 76% at 4 years. Patient survival was 73% at 1 year and 29% at 4 years. Symptomatic status was the only significant predictor of stroke in a long-term period of 4 years (hazard ratio, 1.92; 95% confidence interval, 1.12-3.29; P < .05)., Conclusions: This study, which is the largest population-based study of outcomes after CAS in hemodialysis patients, demonstrates relatively poor long-term survival and prohibitive operative stroke and death risk. We recommend avoidance of CAS in asymptomatic dialysis patients and cautious consideration when planning CAS in symptomatic patients., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The Roll Back Malaria (RBM) Partnership converged in Abuja in 2000. In 2005, Nigeria adopted artemisinin-based combination therapies (ACTs) as first-line therapy for uncomplicated malaria. It was determined that by 2010, 80% of persons with malaria would be effectively treated., Objectives: To describe household practices for malaria treatment in Benin City; to explore demographic characteristics that may influence use of ACTs., Materials and Methods: Multistage sampling technique was used to select households from each of the three local government areas in Benin City. Adult respondents were interviewed. Household reference persons (HRPs) were defined by International Labour Organization categories. Data were collected between December 2009 and February 2010 and were analyzed using Statistical Package for the Social Sciences Version 16.0, at a significance level of P < 0.05 (2-tailed)., Results: Of the 240 households selected, 217 were accessible, and respondents from 90% of these recalled the most recent episode (s) of malaria. One-third of malaria episodes had occurred in children younger than 5 years. ACTs were used in 4.9% of households; sulfadoxine-pyrimethamine was the chief non-ACT antimalarial, followed by artemisinin monotherapies. Patent medicine stores were the most common sources of antimalarial medicines (38.2%), followed by private hospitals (20.3%) and private pharmacies (10.6%). Only 8.3% of households got their medicines from government hospitals. Having a HRP in managerial or professional categories was associated with a 6 times higher odds of using ACTs, compared to other occupational categories [odds ratio (OR) 5.8; confidence interval (CI) 1.470-20.758, P = 0.016]. Fathers' tertiary or higher education was significantly associated with ACT use, but not mothers' (OR 0.054, CI 0.006-0.510; P = 0.011 and OR 0.905, CI 0.195-4.198; P = 0.898, respectively)., Conclusion: Ten years after the historic Abuja meeting, only 5% of households in Benin City used ACTs for the treatment of malaria, sourcing medicines chiefly from patent medicine stores and private hospitals. Fathers' level of education was significantly associated with ACT use. Interventions to eliminate malaria from Nigeria should mainstream the men folk and health care providers outside government hospitals, in line with the Nigerian reality.