Maintenance and salvage of arteriovenous fistulas

PURPOSE: To describe the number and type of percutaneous interventions required to promote maturation and maintain patency of hemodialysis fistulas. MATERIALS AND METHODS: One hundred fifty-four hemodialysis fistulas were created in 146 patients by a single surgeon between August 2001 and March 2005. There were 88 male patients (60%), and the median age of the group was 66 years. The records of all percutaneous procedures performed on these patients were retrospectively reviewed. The medical records from the hemodialysis treatment centers were also reviewed to assess fistula patency during the follow-up period. RESULTS: Of the initial 154 fistulas created, 112 (73%) were successfully used for hemodialysis. One hundred thirteen procedures were performed to promote maturation of 65 fistulas (1.7 procedures per fistula), including 66 venous angioplasty procedures, 16 arterial angioplasty procedures, ligation of 21 venous side branches, five thrombectomy procedures, three banding procedures, and two other procedures. Only 48 of these nonmaturing fistulas (74%) became functional. Sixty-three mature fistulas required 209 procedures (3.3 procedures per fistula, 1.75 procedures per access-year) to maintain vascular access patency. These included 174 venous angioplasty procedures, 18 arterial angioplasty procedures, 14 thrombectomy procedures, ligation of three venous side branches, and two stent placement procedures. The mean follow-up period for all 154 fistulas was 317 days (range, 12-1,138 days). Primary patency rates at 90, 180, and 360 days were 71%, 69%, and 64%, respectively, and secondary patency rates were 73%, 72%, and 68%, respectively. CONCLUSIONS: Percutaneous procedures can promote maturation and maintain patency of arteriovenous fistulas. However, despite numerous procedures to promote maturation, only 74% of nonmaturing fistulas became functional.