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Objectives:
Dialysis access in heavily calcified arteries has proven to be extremely challenging. There is considerable risk for failure of the fistula to mature. Even more concerning, there is an increased risk for steal syndrome and ischemic monomelic neuropathy. Frequently, these challenges lead to patients requiring long-term catheter usage. The current study involved performing atherectomy along with balloon-assisted maturation of forearm fistulae in an effort to maximize maturation and minimize complications.
Methods:
Patients identified as having heavily calcified, but patent radial arteries underwent primary arteriovenous fistulae. During the first portion of the series, this was followed in two weeks with percutaneous atherectomy of the radial artery along with balloon-assisted maturation of the cephalic or basilic veins from a femoral approach. During the later portion of the series, open atherectomy was performed at the same time as fistula creation.
Results:
Over the course of one year, ten patients were found to qualify for the protocol. Of these patients, there was an average of 2.6 failed access attempts prior to the current one. All of the patients in the study were diabetic. None were active smokers. Seven patients had access in their non-dominant extremity. All patients progressed to maturation except for one (the sixth in the series). This patient suffered from fistula thrombosis prior to atherectomy. Subsequent patients underwent percutaneous atherectomy at the time of the fistula creation. One patient suffered from ischemic steal syndrome, causing pain only during hemodialysis. This was treated non-operatively.
Conclusions:
Risk factors for dialysis access complications include small-caliber veins, diabetes, and calcified arteries. Balloon-assisted maturation has been previously described as helping with small-caliber veins. The current study describes a method of dealing with the later two. With a 90 percent maturation rate in this difficult population, there is significant promise with it. An additional benefit of promoting distal forearm creation is minimizing steal syndrome.