The Impact of Reintervention on Arteriovenous Fistula Maturation and Functional Patency in the Hemodialysis Fistula Maturation Study.

Abstract

Rationale & objective: Arteriovenous dialysis fistula (AVF) reinterventions are sought to assist with maturation and/or maintain functional patency; however, their ultimate impact on fistula lifespan remains poorly documented. Furthermore, current clinical practice guidelines lack clarity regarding reintervention paradigms to achieve optimal AVF performance. Therefore, the purpose of this study was to document reintervention rates and their association with AVF maturation and functional patency among patients enrolled in the Hemodialysis Fistula Maturation (HFM) study.

Study design: Retrospective review of a prospective observational cohort study.

Setting & participants: In total, 535 HFM study patients who underwent maturation adjudication across 7 academic centers.

Exposures: Pre- and postmaturation reinterventions (ie, revisional procedures) for single-stage, upper extremity AVFs.

Outcomes: AVF reintervention-associated maturation success and functional patency.

Analytical approach: Descriptive statistical methods, including Kaplan-Meier methodology, characterized unadjusted reintervention outcomes.

Results: In total, 396 (74%) AVFs were successfully used for dialysis, and 37% (N=196 out of 535) underwent 274 reinterventions (181 endovascular, 93 open) to facilitate maturation. Factors associated with prematuration reintervention included female sex, diabetes, peripheral vascular disease, and elevated body mass index. Following maturation, 47% (N=188 out of 396) of the patients with a functional AVF underwent 477 reinterventions. The postmaturation reintervention clinical success rate was 70% (endovascular 72% [N=312 out of 435]; open 55% [N=23 out of 42]). Assisted maturation AVFs demonstrated inferior functional primary patency (P = 0.002) but equivalent cumulative functional patency (P > 0.9) compared with unassisted maturation fistulas. Postmaturation abandonment rate was 24% (N=95 out of 395).

Limitations: AVF management decisions were made by the individual surgeons, so this study cannot account for physician and center selection bias related to access use, remediation, or abandonment. Furthermore, AVFs were exclusively managed at academic institutions, so results may not be generalizable across all health care settings. Finally, prosthetic conduits were not evaluated.

Conclusions: AVF reinterventions are common and are not associated with inferior maturation or functional patency rates. Timely remediation should be considered when clinically indicated, although AVFs remain at high-risk for subsequent reinterventions, with durable outcomes requiring meticulous surveillance.