Future research directions to improve fistula maturation and reduce access failure

Abstract

With the increasing prevalence of end stage renal disease there is a growing need for hemodialysis. Arteriovenous fistulae (AVF) are the preferred type of vascular access for hemodialysis but maturation and failure continue to present significant barriers to successful fistula use. AVF maturation integrates outward remodeling with vessel wall thickening in response to drastic hemodynamic changes, in the setting of uremia, systemic inflammation, oxidative stress and preexistent vascular pathology. AVF can fail due to both failure to mature adequately to support hemodialysis, as well as development of neointimal hyperplasia (NIH) that narrows the AVF lumen, typically near the fistula anastomosis. Failure due to NIH involves vascular cell activation and migration and extracellular matrix remodeling with complex interactions of growth factors, adhesion molecules, inflammatory mediators, and chemokines, all of which result in maladaptive remodeling. Different strategies have been proposed to prevent and treat AVF failure, based on current understanding of the modes and pathology of access failure; these approaches range from appropriate patient selection and use of alternative surgical strategies for fistula creation, to the use of novel interventional techniques or drugs to treat failing fistulae. Effective treatments to prevent or treat AVF failure requires a multidisciplinary approach involving nephrologists, vascular surgeons and interventional radiologists, allowing careful patient selection and the use of tailored systemic or localized interventions to improve patient-specific outcomes. This review provides contemporary information on the underlying mechanisms of AVF maturation and failure and discusses the broad spectrum of options that can be tailored for specific therapy.

Predictive Factors for Unsuccessful Use of Arteriovenous Fistula in a Population of End-Stage Renal Disease Patients in Southeastern Mexico

“…Counter inflammatory mechanisms upregulate procoagulants and inhibit fibrinolysis, causing prothrombotic and hypercoagulable state as a final consequence. These physiopathological events, that might explain the association of short prothrombin time with AVF unsuccessful use, have been mentioned in a recent review by Hu et al 25 In conclusion, ESRD population referred to our center for AVF creation possess different sociodemographic characteristics when compared with that of other vascular access clinics. Nevertheless, good AVF outcomes can be achieved.…”

Survival and Prognostic Predictors of Primary Arteriovenous Fistula for Hemodialysis

“…One possible reason was that DM-induced vascular calcification, 23) which can cause vessel wall stiffness and impairment of blood flow, leads to AVF failure. 24) Furthermore, DM can promote platelet aggregation. 25) This abnormal platelet function can cause endothelial damage and subsequent thrombus formation, thus consequently resulting in AVF dysfunction.…”

Postoperative Ultrasound, Unassisted Maturation, and Subsequent Primary Patency of Arteriovenous Fistulas

“…Arteriovenous fistulas (AVFs) often fail to mature or require surgical or endovascular intervention to achieve maturation (1,2). Even after successful AVF maturation, interventions are frequently necessary to maintain long-term patency for hemodialysis (3,4). Prior studies have evaluated postoperative ultrasound criteria to assess AVF maturation and identify the need for an intervention to promote maturation.…”