Saving Fistula in Case of Distal Ischemia or High Flow: Literature Review of Current Surgical and Endovascular Techniques with Proposal of Decisional Algorithm.

Arteriovenous fistulas (AVFs) are the preferred vascular access for chronic hemodialysis patients due to their lower rates of infectious and thrombotic complications, reduced morbidity and mortality, and increased durability compared to central venous catheters. However, the creation of AVFs has become increasingly challenging due to the rising prevalence of chronic diseases like diabetes, hypertension, and cardiovascular conditions, which are leading causes of end-stage renal disease (ESRD). These comorbidities, coupled with the aging dialysis population, have led to an increase in peripheral vascular diseases, complicating AVF management. This paper discusses two major complications of AVFs: Hemodialysis Access-Induced Distal Ischemia (HAIDI) and high-flow AVFs. HAIDI is characterized by ischemia in extremities due to reduced capillary perfusion, potentially leading to severe outcomes such as tissue necrosis and digital amputations. Approximately 5% of hemodialysis patients with AVFs develop HAIDI, necessitating corrective treatment. High-flow AVFs, defined by excessive blood flow that disrupts overall circulatory dynamics, pose another significant challenge, particularly in patients with cardiovascular compromise. The management of these complications is complex and often requires specialized techniques to preserve the AVF and avoid its closure. This review presents both surgical and endovascular techniques aimed at reducing AVF flow and improving distal perfusion. Techniques discussed include vein approach like ligation, plication, banding, prosthetic graft interposition, and various arterial interventions like distal radial artery ligation and embolization. Additionally, the review presents techniques for anastomosis remodeling, offering innovative approaches to managing AVF complications. The review concludes with a proposed decision-making algorithm to guide clinicians in selecting appropriate interventions based on the specific AVF-related complications, ensuring optimal outcomes for hemodialysis patients. This comprehensive overview highlights the importance of individualized treatment strategies in the management of AVF complications.