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. 2009 Jun;26(2):144-50.
doi: 10.1055/s-0029-1222459.

Optimizing arteriovenous fistula maturation

Steven M Zangan  1 , Abigail Falk
Affiliations

Optimizing arteriovenous fistula maturation

Steven M Zangan et al. Semin Intervent Radiol. 2009 Jun.

Abstract

Autogenous arteriovenous fistulas are the preferred vascular access in patients undergoing hemodialysis. Increasing fistula prevalence depends on increasing fistula placement, improving the maturation of fistula that fail to mature and enhancing the long-term patency of mature fistula. Percutaneous methods for optimizing arteriovenous fistula maturation will be reviewed.

Keywords: Arteriovenous fistula maturation; angioplasty; collateral embolization; dialysis access.

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Figures

Figure 1
Figure 1
Left upper extremity brachiocephalic fistula with multifocal proximal stenoses.
Figure 2
Figure 2
Right forearm radiocephalic fistula that failed to mature due to poor inflow. Atherosclerotic disease affects the native radial artery.
Figure 3
Figure 3
(A) Right upper extremity brachiocephalic fistula with juxta-anastomotic and swing point stenoses. Focal narrowing just proximal to the anastomosis is likely the result of clamp injury. (B) Following 5 mm angioplasty, there is resolution of both stenoses. (C) An additional narrowing involving the cephalic arch also contributed to fistula nonmaturation in this patient. (D) Following 6 mm angioplasty, the cephalic stenosis has improved. Note the diminished flow through collateral veins. Over the course of the following 3 weeks, the fistula became functional.
Figure 4
Figure 4
(A) Left arm brachiocephalic fistula with severe juxta-anastomotic narrowing. Poor clearance was reported during hemodialysis. (B) Following 4 mm angioplasty, the caliber of the fistula improved. After 2 weeks, no further difficulties were encountered.
Figure 5
Figure 5
(A) Left arm radiocephalic fistula that did not mature due to a focal venous outflow narrowing. The focal narrowing in the cephalic vein was likely due to previous venipuncture. (B) Following 5 mm angioplasty, there is no residual stenosis. (C) Two months later, the fistula increased in size and was suitable for dialysis.
Figure 6
Figure 6
(A) Right upper arm brachiocephalic fistula with long segment outflow narrowing. (B) Following 6 mm angioplasty, the stenosis improved. (C) Though the fistula matured, after 7 months the patient developed recurrent stenosis. (D) Angioplasty with a 7 mm balloon again yielded a good technical result. (E) At 12 months, the patient returned with recurrent narrowing. It was resistant to angioplasty and a 7 × 50 mm stent graft was deployed. (F) The stent graft consists of an external nitinol stent and expanded polytetrafluoroethylene (ePTFE) lining.
Figure 7
Figure 7
(A) The left upper extremity brachiobasilic fistula did not mature because of a chronic total occlusion of the left brachiocephalic vein. (B) The narrowing was resistant to angioplasty. A 12 × 60 mm self-expanding stent was placed. Note the resolution of flow through collateral veins.
Figure 8
Figure 8
(A) Left radiocephalic fistula that failed to mature due to multiple accessory veins. (B) The accessory veins were successfully embolized and the fistula matured without further intervention.
Figure 9
Figure 9
(A) Immature left radiocephalic fistula that thrombosed prior to initiation of dialysis. Note the high-grade cephalic arch stenosis and extensive clot in the cephalic vein. (B) After administration of 4 mg alteplase and 6 mm balloon angioplasty, flow was restored and the cephalic arch stenosis improved.
Figure 10
Figure 10
(A) A 46-year-old man presented with a 3-week-old thrombosed immature left radiocephalic fistula. Sequential balloon dilation of the cephalic vein was performed using 2, 3, and 4 mm balloons. The balloon was punctured for retrograde access and the radial artery and anastomosis were dilated with a 2 mm balloon. (B) Flow was reestablished and the fistula became functional. However, 4 months later, there was a decreased thrill on exam and angiography demonstrated a swing point stenosis. (C) Following 6 mm angioplasty, there was resolution of the venous narrowing.
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