W. Perry Arnold, M.D.

Background/Purpose: The National Kidney Foundation Dialysis Outcomes Quality Initiative (DOQI) has recommended AVFs as the preferred hemodialysis vascular access, but they are still greatly underutilized. As more AVFs are created, however, the incidence of primary failure has been reported to increase, and such accesses are generally abandoned. In fact, the reported failure rate in the first 2 months following placement has been reported as high as 40%, usually leading to the need for a temporary, percutaneous access, and prolonging the time to having a functioning permanent access. We have retrospectively reviewed the patients with AVFs referred for evaluation and endovascular intervention during the first three years of operation in a dedicated hemodialysis access interventional practice to document that interventional procedures are highly effective in restoring the function in AVFs that have failed to mature. We have aggressively undertaken the task of promoting the maturation process by endovascular means.

Materials and Methods: During the first 33 months of operation, 223 patients with AVF were seen for evaluation and treatment of hemodialysis access dysfunction. Data were entered into a computerized outcomes database and the results of care of AVFs were analyzed for success of the procedure, patency, and complications. Indications for endovascular treatment included thrombosis, poor flow, inadequate dialysis solute clearance, elevated static venous pressure, and failure to mature.

Results: During the 33 months of the study 382 endovascular procedures were performed for evaluation and correction of AVFs in 223 chronic hemodialysis patients. Of these patients, 43 (20%) presented for evaluation and possible treatment for failure of the AVF to mature into a useable permanent access. Demographics and co-morbid conditions in these patients were similar to those reported by the USRDS for the US dialysis population overall except for a preponderance of males (69% male, 31% female compared to 52% males in the USRDS overall). The procedures performed included serial dilatation, angioplasty and accessory vein ligation, depending on the assessment of the major dysfunction of the AVF. PTA for dysfunctional (and poorly maturing) AVFs had a 97% success rate, and complications were less than 2%. Immature fistulae were converted to fully maturity AVFs in 33/43 (77%) of cases presenting as failure to mature.

Conclusion: Endovascular procedures for immature AVFs can result in a functional access in over 75% of cases. Immature AVFs can be converted to functional accesses by planned aggressive endovascular intervention. The use of endovascular procedures for optimizing the function of AVFs should be expanded, making it more feasible to reach the NKF-DOQI targets for prevalent use of such accesses.