Migration Towards Proximal Location Improves Maturation Rate of Arteriovenous Fistula

In recent years, vascular surgeons have noted that a major drawback to the Fistula First initiative has been the failure of arteriovenous fistulas (AVFs) to reach maturation. In May 2012, we adopted a protocol and hypothesized that such a protocol would lead to a decrease in fistula failures. This was a retrospective study of all dialysis access procedures performed by a single vascular surgeon before (period 1, October 2009 to April 2012) and after (period 2, May 2012 to December 2013) the protocol initiation. The protocol included favoring the brachiocephalic (BC) location unless the patient was an ideal anatomic candidate for a radiocephalic (RC) AVF, creating a larger and standardized arteriotomy, and use of a large venous footplate whenever possible. The main outcome measure was failure to achieve maturation. Secondary outcomes were type of fistula, steal syndrome, time to maturation, and central catheter infections. Of 232 vascular access procedures that were performed, 90.1% were AVFs. There was no difference in use of AVFs over AV grafts between period 1 (93% AVFs) and period 2 (86% AVFs, P = .1). Of 209 AVF, 11 patients (5.3%) were lost to follow-up and 7 (3.3%) were awaiting a second stage procedure, leaving 191 patients with maturation data (Table). BC AVF was performed more often in period 2 (P = .01), with a trend toward decreased use of RC AVF (P = .06). Median arteriotomy size in period 2 was 7 mm. Failure of maturation was significantly decreased in period 2 (odds ratio, 5.0; 95% confidence interval, 1.2-infinite;, P = .03), as was the incidence of central catheter infections (P = .006). There was no difference in steal syndrome (P = 1.0) or time to maturation (P = .3). Creating a standardized AVF protocol resulted in a significant decrease in the rate of AVF failure. This was achieved while maintaining the same high percentage of fistulas, a lower rate of central catheter infections, and the same low incidence of steal syndrome. We were able to decrease rates of AVF failure by following strict anatomic guidelines, including preferential migration to BC location, generous arteriotomy, and use of a large venous footplate.TableComparison of arteriovenous fistula data between study periodsPeriod 1 (n = 94)Period 2 (n = 97)OR (95% CI)PMale gender, No. (%)64 (68)64 (66)1.1 (0.6-2.0).8Brachiocephalic, No. (%)35 (37)54 (56)0.6 (0.3-0.8).01Radiocephalic, No. (%)34 (36)22 (23).06Superficialization, No. (%)25 (27)20 (21)1.4 (0.7-2.7).3Diabetes, No. (%)65 (69)60 (62)1.4 (0.8-2.5).3Tobacco use, No. (%)10 (11)4 (4)2.8 (0.8-9.2).1Maturation time, median (IQR) days69 (45-110)56 (44-106).3Failure of Maturation, No. (%)9 (10)2 (2)5 (1.1-23.9).03Steal, No. (%)3 (3)4 (4)0.8 (0.2-3.5)1Central catheter infection, No. (%)7 (7)0NA.006CI, confidence interval; IQR, interquartile range; OR, odds ratio. Open table in a new tab