Predictors of Maturation Failure in Arteriovenous Dialysis Access.

Objective: Failure of arteriovenous fistula (AVF) maturation results in unnecessary patient risk and resource waste. We sought to identify potentially addressable risk factors for fistula failure-to-mature (FTM) to cannulation readiness.

Methods: We conducted a single-institution retrospective review of patients undergoing primary AVF creation from 2015-2021. Fistula configuration was based on bedside preoperative ultrasound. Cannulation readiness (maturation) was determined primarily by surgeon physical examination. Demographics, comorbidities, and follow-up procedures (balloon-assisted maturation (BAM), surgical-assisted maturation (SAM; includes branch ligation, unplanned superficialization), and steal interventions) were recorded. Univariate and multivariate analyses (univariate p<0.1) were performed exploring associations between patient/surgical factors and FTM within one year.

Results: 363 patients underwent creation of a new AVF. Fourteen (3.7%) were lost to follow up before maturation/abandonment and were excluded from analysis. Of those remaining, 80 (23%) were never successfully used. Death within one year, peripheral arterial disease (PAD), and median antecubital vein (MACV) fistula were associated with FTM on univariate and multivariate analysis. Nearly half (42%) of MACV fistulas failed to mature. BAM was successful in 29/48 (60%) cases but was associated with fistula non-maturation on univariate and multivariate analysis. Neither age, sex, non-PAD comorbidities, prior AV access, nor radiocephalic fistula (RCAVF) were associated with FTM. Female and older patients were much less likely to receive a RCAVF.

Conclusions: Over one-fifth of AV fistulas did not achieve cannulation readiness. Improved patient/procedure selection, avoiding the use of the MACV and construction in those at high risk of death within one year may help improve maturation rates. RCAVF can be expected to mature in well-selected patients. BAM is associated with maturation in over half of cases and should be considered in nonmaturing fistulas.