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

TL;DR

This study shows that AVF reinterventions are common and do not reduce long-term dialysis access success, though they require careful monitoring.

Contribution

The study provides evidence on the frequency and outcomes of AVF reinterventions in a large observational cohort.

Findings

37% of AVFs underwent prematuration reinterventions, with 47% of functional AVFs requiring postmaturation procedures.

Postmaturation reinterventions had a 70% success rate, with no significant difference in overall functional patency.

Prematuration AVFs had worse primary patency but similar cumulative patency compared to unassisted AVFs.

Abstract

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.

Retrospective review of a prospective observational cohort study.

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

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

AVF reintervention-associated maturation success and functional patency.

Descriptive statistical methods, including Kaplan–Meier methodology, characterized unadjusted reintervention outcomes.

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).

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.

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.

The Hemodialysis Fistula Maturation (HFM) study was reviewed to analyze how often arteriovenous fistulas (AVFs) required additional procedures (reinterventions) and how successful these procedures were in ensuring functional access. Reinterventions were categorized as either prematuration (to promote AVF maturation) or postmaturation (to address AVF malfunction). More than one-third of AVFs required a prematuration reintervention, with about half of these being successful. Patients at higher risk for requiring interventions included those who were female, had diabetes, peripheral vascular disease, or a high body mass index. Postmaturation reinterventions were performed in about half of mature AVFs, with a success rate of 70%. Although AVFs needing prematuration interventions had lower rates of freedom from reintervention after maturation, their overall functional patency was comparable with AVFs that did not require early intervention. These findings suggest that AVF reinterventions are common but do not compromise long-term access durability.

Figures