VESS19 - The Futile Fistula: Predicting Maturation Failure in Arteriovenous Dialysis Access

Objectives: 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 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: 381 patients underwent AVF creation. Fourteen (3.7%) were lost to follow up before maturation/abandonment and were excluded from analysis. Of those remaining, 82 (22%) 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 (Table I). Nearly half (42%) of MACV fistulas failed to mature. BAM was successful in 30 (60%) cases but was associated with fistula non-maturation on univariate and multivariate analysis. All 12 fistulas undergoing both SAM and BAM matured. Patients who died within 1 year (n=22, 6%) were significantly older at fistula creation (67+/-10 years vs. 58+/-12 years, p=0.0004). Neither age, non-PAD comorbidities, prior AV access, nor radiocephalic fistula (RCAVF) were associated with FTM.

Conclusions: Over one-fifth of AV fistulas did not achieve cannulation readiness. Improved patient/procedure selection, avoiding those with potentially short life expectancy and avoiding use of the MACV 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.