Adjunct Procedures for Non-Maturing Arteriovenous Fistula: How Well Do They Work?
Sami Assi, MSH, Animesh Rathore, MD, Limael E. Rodriguez, MD, David Dexter, MD, Jean M. Panneton, MD.
Eastern Virginia Medical School, Norfolk, VA, USA.
OBJECTIVES: Arteriovenous fistulas (AVF) for dialysis access are often associated with failure of maturation for cannulation in up to 23-41% patients. Adjunct procedures commonly performed to achieve AVF maturation have not been assessed in the recent literature. The aim of this study is to evaluate these adjuncts and the predictors of success in access maturation.
METHODS: Patients undergoing adjunct procedures for AVF maturation between January 2015 and May 2017 were retrospectively studied. Demographics, comorbidities, procedural details, graft duplex ultrasound findings, and patency data were collected. The primary endpoints were time to maturation, number of adjuncts performed, and reinterventions needed after the adjunct procedure. Secondary endpoints were reintervention rates, and primary and secondary patency.
RESULTS: 73 AVFs in 69 patients (M:F 45%, median age of 59 years) needed adjunct procedures to promote maturation. A total of 157 adjunct procedures (2.2 per AVF) were needed, including 40 arterial, 23 venous, and 11 central vein angioplasties, 38 side branch ligations, 20 superficializations, 8 thrombectomies, 7 steal syndrome procedures, and 5 other procedures. 53/73 (72%) AVFs matured and were successfully cannulated for hemodialysis in a mean time of 71 days after the adjunct procedure. History of prior access thrombosis (45% vs 21%, p=0.038), findings of arteriovenous anastomotic stenosis on graft duplex ultrasound within 30 days of fistula creation (42% vs 14%, p=0.015), and symptomatic central stenosis within 30 days of fistula creation (26% vs 6%, p=0.017) were significantly associated with failure of adjunct procedures in remaining patients (20/73, 28%). The 53 AVFs that matured required 84 additional procedures (1.6 per fistula, 1.22 per access-year) to maintain vascular access patency. These reinterventions included 25 venous, 17 arterial, and 16 central vein angioplasties, 12 thrombectomies, 9 stenting and 3 other procedures. Mean follow-up was 437 days. Primary patency at 3, 6, 12, and 24 months were 68%, 47%, 38%, and 13%, respectively, and secondary patency, 77%, 68%, 54%, and 21%, respectively.
CONCLUSIONS: Adjunct procedures can successfully achieve maturation in majority of non-maturing AVFs. Prior access thrombosis, early arterial anastomotic stenosis and early symptomatic central venous stenosis are significant predictors for failure of these adjunct procedures.
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