Impact of secondary procedures in autogenous arteriovenous fistula maturation and maintenance - Discussion

Purpose: The purpose of this study was to evaluate the impact of secondary procedures to facilitate maturation of autogenous arteriovenous (AV) fistulas and optimize their use for hemodialysis access. Methods: The records of patients undergoing new autogenous AV fistulas were reviewed. Analyses of fistula maturation, subsequent interventions, access function, and patency were performed. Results: From July 1998 through June 2000, 362 new AV access fistulas and grafts were constructed in 310 patients. In this cohort, 170 autogenous fistulas (55%) were placed in 163 patients. Fistula types included 115 antecubital brachiocephalic fistulas (Kaufmann) (68%), 47 radiocephalic fistulas (Brescia-Cimino) (28%), and 8 basilic vein transposition fistulas (4%). Secondary procedures were required in nine cases (5%) for failure to mature (4 Brescia-Cimino, 5 Kaufmann) and included 3 vein patches, 3 interposition vein grafts, 1 transposition to a more proximal artery, 1 branch ligation, and 1 balloon angioplasty of the subclavian artery; they occurred at 4.4 ± 2.1 months (mean ± SD). Additional procedures were needed to revise patent but failing fistulas in six cases (3.5%; 3 Brescia-Cimino, 3 Kaufmann) and included 5 transpositions to a more proximal artery and 1 vein patch; they occurred at 12.3 ± 5.6 months (P = .002 compared with immature fistulas). For this series of autogenous fistulas, a functional access was achieved in 129 of 143 patients (90%) for whom follow-up was available. Twelve-month actuarial primary patency for autogenous fistulas was 78% compared with 49% for prosthetic grafts placed in the same period (P = .001, log-rank). Conclusions: In the current series, a 10% improvement in accomplishing or maintaining a functional autogenous access was achieved through secondary procedures applied to autogenous fistulas that either fail to mature or develop functional deterioration. Aggressive assessment of immature or failing autogenous AV fistulas for correctable lesions should be included in any hemodialysis practice to optimize their use and exploit the superiority of the native fistula.