Endovascular Treatment of the “Failing to Mature” Arteriovenous Fistula

Abstract

In recent literature, surgically created hemodialysis (HD) arteriovenous fistulas (AVF) have high rates of primary failure. Endovascular treatment holds promise to salvage these fistulae. The outcomes of 119 patients who had a "failing to mature" AVF and presented for endovascular management were evaluated prospectively. All patients underwent a fistulogram. Stenotic lesions underwent balloon angioplasty, and accessory veins underwent obliteration. Technical success was determined immediately after the procedure. AVF salvage was determined by successful use during HD. Patients were followed up for 1 yr, during which primary and secondary AVF patency rates were measured. T he low prevalence of the arteriovenous fistula (AVF) among US hemodialysis (HD) patients (1,2) has initiated nationwide measures to increase AVF creation and prevalence (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20). Among these are providing educational programs, setting forth guidelines and goals (3,4), implementing multidisciplinary approaches (4 -9), encouraging preoperative venous mapping (14 -19), and asking surgeons to create AVF instead of arteriovenous grafts (AVG) (10 -21).Overall, an increase in AVF prevalence is occurring in the United States, albeit at a slow rate (14 -20). One impediment has been high primary failure rates, which in recent series ranged between 23 and 46% (9,(12)(13)(14). The use of ultrasound or other means of preoperative venous mapping is likely to decrease the incidence of primary AVF failures (14 -19). However, the increasing demand to create more fistulas may lead to their creation in borderline vessels, thereby increasing primary failure rates (21-23). Thus, salvage of these primary failures will be essential for increasing AVF prevalence in the United States.In our dedicated endovascular suite, we used percutaneous angioplasty and accessory vein obliteration in attempts to salvage fistulas with primary failure. Because most did not present with thrombosis, we elected to refer to their fistulas as "failing to mature." In this article, we report our initial success rates as well as follow-up on a series of 119 consecutive patients who were referred for salvage of their "failing to mature" AVF. Materials and Methods DefinitionsThe "failing to mature" AVF in our series was defined as an AVF that had been created for at least 8 wk but had not matured enough to allow successful cannulation or use during HD. This includes (1) fistulas that were never cannulated for HD be cause of obvious lack of maturity; (2) fistulas that failed first cannulation attempts and were abandoned; (3) fistulas that were cannulated successfully but could not be used because the blood flow was insufficient to sustain HD; this may have been because of high venous pressure or poor arterial inflow; and (4) fistulas that thrombosed before any attempts at HD. Juxta-arterial anastomosis segment refers to the initial 5 cm of the AVF starting at the arterial anastomosis. Peripheral vein refers to the venous outflow tract of t...

Dialysis Fistula or Graft

“…Nonmaturing fistulas frequently have an underlying anatomic problem, such as perianastomotic stenosis or presence of accessory veins, which can be visualized by an ultrasound or angiogram. Aggressive endovascular or surgical interventions to correct the underlying anatomic problem can frequently salvage an immature fistula and make it suitable for dialysis use (47)(48)(49)(50). However, such interventions may have a negative effect on long-term fistula outcomes.…”

Autogenous Sapheonus Vein Graft Interposition in Arteriovenous Fistula Formation

“…Bu amaçla daha çok üst ekstremite venleri kullanılmakta-dır. Üst ekstremite venlerinin 2 mm altında olduğu durumlarda greft yetmezliği veya trombozu riski yüksektir [3][4][5]. Kidney Disease Outcomes Quality Initiative (KDOQI) adlı kurum kılavuz-larına göre radiyo-sefalik ve brakio-sefalik AVF lokalizasyonları gibi ideal bir AVF için elverişli damar bulunmayan hastalarda alternatif AVF yöntemleri gündeme gelmektedir [10][11][12][13].…”

Guidelines for basic techniques in vascular access intervention therapy (VAIVT)

“…Poor maturation immediately after creation of a VA 11,27,69,72,88 is generally recognized when development remains poor 1 month after VA creation. Occlusion immediately after VA creation is also considered an indication for VAIVT, but in such cases VAIVT should be performed at least two weeks after VA construction.…”