The role of surgery for assisted maturation after endovascular and percutaneous arteriovenous fistula creation

Abstract

Even in the best of circumstances, a significant number of patients will require adjunctive endovascular and/or surgical revision prior to achieving functional patency after endovascular or percutaneous AVF creation, at least within the United States. This rate appears to be higher after percutaneous AVF than after endovascular AVF, although because published reports of the former are mostly derived from American experience and those of the latter derived from experience outside the United States, it is unclear whether these differences are due to the technique itself or cultural and/or anatomic differences in dialysis access practices and patient populations. If arterial inflow is poor, this should be corrected first. When flow is adequate (perhaps 900 cc/min) but no single vein is cannulatable, a dominant suitable vein can be superficialized or transposed. If no suitable vein is dominant (most accurately assessed by using an intraoperative flowmeter), the best vein can be used, with or without occlusion of the other veins or reimplantation into the brachial artery. Finally, if the original anastomosis remains the sole supply to the cannulated vein, the original fistula has achieved assisted primary maturation (and assisted primary patency continues), while if a new arteriovenous anastomosis has been constructed, the original fistula has failed. We point out that for this reason as well as to best utilize the upper arm for later access, endovascular and percutaneous AVFs should be constructed and maintained within an atmosphere where both surgeons and non-surgeons work together on the overall access plan.

Dialysis Access-Associated Steal Syndrome with Percutaneous Endovascular Arteriovenous Fistula Creation.

“…Four vascular beds that contribute to the pathophysiology of DASS are [1,3]: DASS is also a factor in AVG, and is related to the larger diameter of the anastomosis relative to the artery. A smaller anastomotic diameter of 5 mm created by WavelinQ technology can also result in symptomatic steal [4]. Treatment is based on the severity of symptoms, and is often not required with mild DASS.…”

Molecular Insights and Novel Approaches toward Individualized Arteriovenous Fistula Care

“…More recently, noninvasive endovascular and percutaneous techniques have been used effectively for forearm AVF creation. These procedures showed comparable safety, patency rates with increased patient satisfaction [2].…”