Improved Cumulative Survival in Fistulas Requiring Surgical Interventions to Promote Fistula Maturation Compared with Endovascular Interventions

Abstract

Due to high non-maturation rates, arteriovenous fistulas (AVF) frequently require intervention(s) to promote maturation. Endovascular or surgical interventions are often undertaken to salvage non-maturing AVFs. The objective of this study was to compare the impact of surgical versus endovascular interventions to promote AVF maturation on cumulative AVF survival. We evaluated 89 patients with new AVF placement from a Veterans Affairs population over a 5-year period. Of these, 46 (52%) required intervention(s) to achieve successful maturation for dialysis. 31 patients had surgical revisions and 15 patients had endovascular repairs. We compared cumulative survival between AVFs requiring no intervention, surgical revision, and endovascular intervention to promote AVF maturation. Cumulative survival was longer in AVFs receiving surgical intervention compared to angioplasty to promote AVF maturation (p=0.05). One year cumulative survival was 86% vs 83% vs 40% for no intervention vs. surgery vs. angioplasty, respectively. In AVFs that required interventions to promote maturation, AVFs with surgical intervention had longer cumulative survival compared to those AVFs with endovascular intervention. AVFs with surgical intervention to promote maturation had similar one-year cumulative survival to those AVFs that did not require intervention to promote maturation.

Surgical and Endovascular Intervention for Dialysis Access Maturation Failure During and After Arteriovenous Fistula Surgery: Review of the Evidence

“…AVFs with surgical intervention for FTM had a similar one year cumulative patency to those AVFs that did not require intervention to promote maturation. 60 Similar results were found in a consecutive series of 73 patients with AVF non-maturation and JAS, treated either by surgery (21) or PTA (52). Surgery meant creation of a proximal neo-anastomosis excluding the area of stenosis.…”

“…The vessel injury resulting from angioplasty is usually greater than that obtained by surgical revision. 54,60 The few studies on endovascular versus surgical intervention show better outcome for the surgical group, in particularly for primary patency which ranges from 68% to 94% compared with a dismal 28% to 72% patency in endovascularly treated patients. In the latter group repeated PTA is needed to achieve a 68% to 97% AVF cumulative survival rate after 1 year of follow-up.…”

Changes in the Profile of Endovascular Procedures Performed in Freestanding Dialysis Access Centers over 15 Years

“…There are several issues that have grown out of the push to increase AVF utilization that might explain this. In addition, multiple studies (22)(23)(24) have shown that a salvaged FTM-AVF requires additional interventions to maintain its patency. However, if all AVFs that are created are considered, the primary patency of AVFs and AVGs is comparable for the first year after creation because of AVF FTM (16)(17)(18).…”

Vascular Access Surveillance: Time to End the Controversy

“…Data from a number of small randomized studies suggest a benefit for the surgical treatment of thrombosed arteriovenous grafts versus angioplasty ; however, these studies were performed in the 1990s. Other recent data suggest a benefit of surgery over angioplasty in arteriovenous fistulae that have failed to mature .…”