Aggressive Approach to Salvage Non-Maturing Arteriovenous Fistulae: A Retrospective Study with follow-up

Abstract

Fistula salvage attempts should not be limited by factors such as a diffusely small diameter or an inaccessibly deep position.

Decreased Cumulative Access Survival in Arteriovenous Fistulas Requiring Interventions to Promote Maturation

“…In particular, we are completely cognizant of the fact that a lack of intervention would likely have resulted in primary AVF failure in the patients in the intervention group (46). However, we do want to bring to the attention of the dialysis access community the fact that multiple interventions may have at least some negative effect in the long term, both on survival and on the number of interventions required to maintain patency.…”

Balloon-Assisted Maturation (BAM) of the Arteriovenous Fistula: The Good, the Bad, and the Ugly

“…An important technical aspect of the procedure is to dilate up the venous outflow which has a direct line access into the upper arm cephalic or basilic system, while at the same obliterating other collaterals (accessory veins) through percutaneous ligation or coiling techniques. 25,26,40 Another intriguing aspect is the preferred use of controlled venous rupture during angioplasty in many instances in order to generate fibrous tissue around the AVF. 27 More recently a number of authors have described the use of primary balloon angioplasty at the time of surgery to dilate veins as small as 1–1.5mm prior to creation of an AVF, followed by BAM.…”

“…The one year secondary patency’s were 72% and 77%. 25 The number of post-maturation angioplasties per year in order to maintain future patency was not provided. Miller and colleagues more recently, described the use of aggressive balloon assisted maturation in 140 consecutive patients with thrombosed AVFs.…”

“…Of note, this aggressive angioplasty approach is often combined with the use of coiling or percutaneous ligation to direct flow down the most direct pathway to the central circulation. 25,26 In addition, recent papers have described the use of intra-operative “primary balloon angioplasty” at the time of surgery which could allow for AVFs to be created in patients with small arteries and veins (artery < 2mm and vein <2.5mm). 27,28 …”

Strategies to Assist Fistula Maturation and Successful Use for Hemodialysis

“…BAM can be performed antegradely through arterial puncturing or using retrograde approach puncturing the venous fistula proximally. 4 If the venous access is still small in size, arterial access is preferred. In partially dilated venous fistula, the venous access can be achieved using ultrasound guidance.…”