Risk Factors for Early Failure of Native Arteriovenous Fistulas

Abstract

Introduction: Current guidelines recommend native arteriovenous fistulas (AVF) as the vascular access of choice for hemodialysis on account of the lower incidence of complications. However, this kind of vascular access has a high rate of early failure (early thrombosis or non-maturation). Our aim was to examine whether clear risk factors for early AVF failure could be identified in our patients. Subjects and Methods: Data of all patients who underwent creation of an AVF at the Geneva University Hospital from January 1998 to December 2002 were reviewed. Early failure was defined as a non-functioning fistula (thrombosis or absence of fistula maturation). Results: 119 patients underwent the creation of 148 native AVF, 88 (59.5%) in the forearm and 60 (40.5%) in the upper arm. 48 (32.4%) fistulae were created in diabetic patients. In a multiple logistic regression analysis, significant predictive factors of early failure were a distal location (adjusted odds ratio (aOR) = 8.21, 95% CI = 2.63–25.63, p < 0.001), female gender (aOR = 4.04, 95% CI = 1.44–11.30, p = 0.008), level of surgical expertise (aOR = 3.97, 95% CI = 1.39–11.32, p = 0.010) and diabetes mellitus (aOR = 3.19, 95% CI = 1.17–8.71, p = 0.024). Conclusion: Early failure of AVF occurs mainly in forearm sites among women and diabetic patients. Surgical expertise has also a significant influence. These results suggest that selection of a distal site for a native AVF has to be rigorously made for women and diabetic patients and that surgeon’s dedication is of primary importance to avoid early AVF failure occurrence.

Risk Equation Determining Unsuccessful Cannulation Events and Failure to Maturation in Arteriovenous Fistulas (REDUCE FTM I)

“…Perhaps as a result of the close relationship between predictive factors and pathophysiology, the location of the fistula in the lower or upper arm did not factor into our prediction rule because adequate inflow and outflow are required irrespective of fistula location. This is consistent with some studies (18,22), whereas others found improved maturation in upper arm fistulas (12,35). This same reasoning may be applied to gender.…”

“…The clinical consequences of immature fistulas include prolonged dependence on "bridging catheters" with all of the attendant complications, patient inconvenience, need for further attempts at permanent access surgery, and risk for eventual patient refusal (8,11). Even in programs that use routine preoperative vascular mapping to guide the surgeon's choice of access type and location, primary failure still occurs in a subset of patients (12,13). In promoting fistula creation and use, it would be ideal to be able to predict which patients would benefit from an AVF that would mature successfully, without excessive intervention, and to tailor access placement accordingly.…”

New Insights into Dialysis Vascular Access: What Is the Optimal Vascular Access Type and Timing of Access Creation in CKD and Dialysis Patients?

“…Studies conflict regarding the association between women, AVF nonmaturation, and reduced patency (6)(7)(8)(9), which is hypothesized to be related to smaller diameter veins in women compared with men. This is difficult to assess, because many studies do not perform preoperative vein mapping or report vein diameters.…”

Diabetes should not dissuade arteriovenous fistula formation

“…18,19 There is evidence suggesting an increased failure in smaller radiocephalic fistulas, or cases with increased steal syndrome, which were attributed to microvascular damage associated with diabetes; these may not be relevant due to the numerous confounding factors associated with this population. 20,21 Our small sample size is a limitation of our study and conclusions based on these results are limited. However, the conclusions drawn from the results support and add to existing evidence.…”