Prospective evaluation of failure modes in autogenous radiocephalic wrist access for haemodialysis

Introduction. Radiocephalic wrist arteriovenous fistulae (RCAVF) are the primary and best option for vascular access for haemodialysis treatment. However, 10-24% of these AVFs fail due directly to thrombosis and non-maturation. In a prospective study, the failure modes of radiocephalic AVFs and the impact of surgical and interventional treatment on fistula outcome were investigated. Methods. The rate of thrombosis and non-maturation was evaluated in 43 RCAVFs. The selection of RCAVF creation was made on preoperatively determined duplex parameters. Fistula function was evaluated post-operatively by clinical examination and non-invasively measured AVF blood flow. A policy of a liberal use of radiological and/or surgical revision of non-functioning RCAVFs was made on the basis of duplex measured blood flow and angiographically detected vessel stenosis. Results. Primary fistula function was achieved in 26 of 43 patients (60%). Non-maturation and thrombosis occurred in 14 (33%) and three (7%) patients, respectively. A total of 12 interventions (PTA 6; surgery 6) were needed, resulting in salvage of eight RCAVFs (47%). The blood flow in functioning AVFs was significantly higher compared to non-functioning AVFs at 1 (754 vs 440 cc/min), 7 (799 vs 524 cc/min) and 42 days (946 vs 532 cc/min) post-operatively. At the end, 34 RCAVFs (79%) became functional as vascular access for haemodialysis treatment. Conclusion. Primary RCAVFs have a high rate of failure. An aggressive approach towards early interventional treatment of these non-functional AVFs is worthwhile and leads to a considerable salvage rate. Early post-operative AVF flow measurement indicates the chance of successful maturation of RCAVF.