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Measure Twice, Cut Once: Arterial Diameter Dictates AVF Maturation Outcomes
Gear T. Vincent, BS, MS Mia Cranmer MS, Thomas Cook, Ahmad Alsheekh MD, Daniel Steadman MD, Hosam El Sayed MD, Jean Panneton, MD.
Eastern Virginia Medical School, Norfolk, VA, USA.
OBJECTIVES: Arteriovenous fistulas (AVFs) remain the preferred access for hemodialysis in end-stage renal disease (ESRD). Diabetes mellitus is a leading cause of chronic kidney disease (CKD) and ESRD, yet the determining factors of AVF maturation in this population is unclear. This study aimed to evaluate the impact of demographic and surgical factors on AVF maturation and identify anatomical and surgical predictors of successful maturation.
METHODS: We performed a retrospective review of 1,200 consecutive patients undergoing initial autogenous AVF creation between January 2008 and November 2022 at a single academic institution. Patients with type 1 diabetes, prior access, or non-autogenous grafts were excluded. Cohorts were stratified as non-diabetic, diabetic-diet controlled, diabetic-oral therapy, or diabetic-insulin therapy. The primary endpoint was AVF maturation, defined by clinical usability for dialysis. Multivariable logistic regression was used to identify independent predictors of maturation.
RESULTS: A total of 807 patients (≥18 years old) underwent 807 AVF creations. Anatomical and procedural factors were the only factors of statistical significance. Larger preoperative artery diameter independently predicted successful maturation (OR >1.0, p<0.05). Requirement of ≥2 staged procedures significantly reduced odds of maturation. Multivariable analysis confirmed arterial diameter as the strongest predictor of maturation, while no other factors had a statistically significant impact.
CONCLUSIONS: In this large institutional series, diabetes status, method of glycemic control, and HbA1c levels, and numerous other factors were not predictive of AVF maturation. Instead, preoperative artery diameter and surgical approach were the primary determinants of success. These findings suggest that surgical planning for AVF creation should minimize multi-step procedures and emphasize anatomical suitability with efforts focused on optimizing vessel selection to improve maturation outcomes.
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