Impact of reintervention for failing upper-extremity arteriovenous autogenous access for hemodialysis

Purpose. Although large published series have described their experience with the management of failed or failing prosthetic arteriovenous grafts for hemodialysis, there are scant data regarding failing arteriovenous fistulae (AVFs). To analyze the management of nonfunctioning or nonmaturing AVFs, we reviewed our experience with salvage procedures for these AVFs. Material and Methods: Of the 474 AVFs placed at our institution in 380 patients between June 1997 and March 2001, 75 revisions were performed in 46 patients (49 AVFs). Ages of these patients ranged from 29 to 94 years (mean, 68 +/- 1.4 years). Diabetic patients comprised 51%, and hypertensive patients comprised 75%. Twenty patients underwent 26 vein patch angioplasties, and 17 patients underwent 24 balloon angioplasties. Four patients required four vein interpositions, and 12 patients underwent 12 revisions of the fistula to a more proximal level. Extended salvage procedures consisted of four turn-downs to the basilic vein for proximal cephalic vein thrombosis or stenosis and five extension bypasses to the axillary or jugular vein for subclavian vein thrombosis. Results: Follow-up ranged from 1 to 31 months (mean, 10 months). The patients who underwent open revisions tended to need fewer subsequent procedures. However, primary patency of the vein patch angioplasty was not significantly better as compared with balloon angioplasty (P = .8) by life table analysis. Patency after revision of a radial cephalic fistula and brachial cephalic fistula were not statistically different. One interposition failed during the follow-up, and one revision to a more proximal level thrombosed during the follow-up. Two of the turn-down procedures had thrombosed at 2 and 11 months. The remaining two turn-down procedures have remained functional at 1 and 24 months. One of the extensions thrombosed at 8 months whereas the other four have remained functional at 1, 6, and 8 months. Conclusions: Despite the limited follow-up data, this review suggests that simple and extended salvage procedures may allow maturation and add to the life span of AVFs for hemodialysis. In addition, these data suggest an advantage for open techniques as compared with percutaneous techniques but only in terms of requiring fewer subsequent procedures.