Arteriovenous Fistula Maturation, Functional Patency, and Intervention Rates

Abstract

National initiatives have emphasized the use of autogenous arteriovenous fistulas (AVFs) for hemodialysis, but their purported benefits have been questioned. OBJECTIVE To examine AVF usability, longer-term functional patency, and remedial procedures to facilitate maturation, manage complications, or maintain patency in the Hemodialysis Fistula Maturation (HFM) Study. DESIGN, SETTING, AND PARTICIPANTS The HFM Study was a multicenter (n = 7) prospective National Institutes of Health National Institute of Diabetes and Digestive and Kidney Diseases cohort study performed to identify factors associated with AVF maturation. A total of 602 participants were enrolled (dialysis, kidney failure: 380; predialysis, chronic kidney disease [CKD]: 222) with AVF maturation ascertained for 535 (kidney failure, 353; CKD, 182) participants. INTERVENTIONS All clinical decisions regarding AVF management were deferred to the individual centers, but remedial interventions were discouraged within 6 weeks of creation. MAIN OUTCOMES AND MEASURESIn this case series analysis, the primary outcome was unassisted maturation. Functional patency, freedom from intervention, and participant survival were summarized using Kaplan-Meier analysis. RESULTSMost participants evaluated (n = 535) were men (372 [69.5%]) and had diabetes (311 [58.1%]); mean (SD) age was 54.6 (13.6) years. Almost two-thirds of the AVFs created (342 of 535 [64%]) were in the upper arm. The AVF maturation rates for the kidney failure vs CKD participants were 29% vs 10% at 3 months, 67% vs 38% at 6 months, and 76% vs 58% at 12 months. Several participants with kidney failure (133 [37.7%]) and CKD (63 [34.6%]) underwent interventions to facilitate maturation or manage complications before maturation. The median time from access creation to maturation was 115 days (interquartile range [IQR], 86-171 days) but differed by initial indication (CKD, 170 days; IQR, 113-269 days; kidney failure, 105 days; IQR, 81-137 days). The functional patency for the AVFs that matured at 1 year was 87% (95% CI, 83.2%-90.2%) and at 2 years, 75% (95% CI, 69.7%-79.7%), and there was no significant difference for those receiving interventions before maturation. Almost half (188 [47.5%]) of the AVFs that matured had further intervention to maintain patency or treat complications. CONCLUSIONS AND RELEVANCEThe findings of this study suggest that AVF remains an accepted hemodialysis access option, although both its maturation and continued use require a moderate number of interventions to maintain patency and treat the associated complications.

Percutaneous endovascular arteriovenous fistula: A systematic review and meta-analysis

“…Although AVF is the preferred access in hemodialysis patients, low maturation rate is a challenging problem. Some multiple-center prospective cohort studies have shown AVF maturation success rates of only 60 to 67% ( 33 , 34 ). And studies have indicated that 35 to 50% of surgical AVF required intervention prior to successful use in hemodialysis ( 35 – 37 ).…”

The arteriovenous fistula and the history of a forgotten pioneer

“…16 Despite these promising results, the arteriovenous shunts developed during this period preceding the advent of the radiocephalic fistula continued to cause problems. Often referred to by the eponym, "Quinton-Scribner shunt," the PTFE shunt, though a marked improvement from its predecessors, was associated with complications such as local bleeding, shunt occlusion, decreased blood flow, 6 dislodgement of the external component of the shunt, and distal limb ischemia. 5 Although the risk of infection was reduced by the use of the subcutaneous tunnel, phlebitis and cellulitis still occasionally occurred at the cannulation site, leading to an elevated risk of septicemia and pulmonary emboli.…”

Technological innovation in vascular access surgery: a reflection on two recent developments

“…Rather than describe endoAVF outcomes in terms of primary and secondary patency, which are often misused and interchanged,10 a more clinically applicable outcome is that of functional patency—whether an AVF is currently being used for dialysis 27. Berland et al ’s work demonstrated a functional patency rate of 94.5% at 6 months24 whereas NEAT found only 64% of endoAVFs suitable for dialysis within 12 months.…”