ASDIN Original Investigations: Salvage of a Severely Dysfunctional Arteriovenous Fistula with a Strictured and Occluded Outflow Tract

Pre-Access Creation Evaluation--Is Vein Mapping Enough?

The changing demographic of the hemodialysis population in the United States is posing significant challenge for selection and creation of an optimal vascular access. An arteriovenous fistula (AVF) is by far the most reliable access provided it matures and functions successfully. System-wide changes implemented by Fistula First Breakthrough Initiative and Kidney Disease Outcomes Quality Initiative guidelines have increased the awareness and incidence of AVF in the prevalent dialysis population; however, achieving the current goal of 68% AVF rate continues to remain elusive. The present article reviews the evidence in literature in support of and against using vessel mapping alone as a strategy to improve AVF rate. The current strategy of evaluating the vessels before an access is created seems to be inadequate. A patient-centered approach for an optimal vascular access needs to be considered to improve the AVF rate.

Early Arteriovenous Fistula Failure: A Logical Proposal for When and How to Intervene

A significant number of arteriovenous fistulae (28 to 53%) never mature to support dialysis. Often, renal physicians and surgeons wait for up to 6 months and even longer hoping that the arteriovenous fistula (AVF) will eventually grow to support dialysis before declaring that the AVF has failed. In the interim, if dialysis is needed, then a tunneled catheter is inserted, exposing the patient to the morbidity and mortality associated with the use of this device. In general, a blood flow of 500 ml/min and a diameter of at least 4 mm are needed for an AVF to be adequate to support dialysis therapy. In most successful fistulae, these parameters are met within 4 to 6 wk. Most important, commonly encountered problems (stenosis and accessory veins) that result in early AVF failure can be diagnosed easily with skillful physical examination. Recent studies have indicated that a great majority of fistulae that have failed to mature adequately can be salvaged by percutaneous interventions and become available for dialysis. Early intervention regarding identification and salvage of a nonmaturing AVF is critical for several reasons. First, an AVF is the best available type of access regarding complications, costs, morbidity, and mortality. Second, this approach minimizes catheter use and its associated complications. Finally, access stenosis is a progressive process and eventually culminates in complete occlusion, leading to access thrombosis. In this context, the opportunity to salvage the AVF that fails early may be lost. This report reviews the process of AVF maturation and suggests a strategy for when and how to intervene to identify and salvage AVF with early failure.