Complications of the Arteriovenous Fistula: A Systematic Review

Abstract

The implementation of patient-centered care requires an individualized approach to hemodialysis vascular access, on the basis of each patient's unique balance of risks and benefits. This systematic review aimed to summarize current literature on fistula risks, including rates of complications, to assist with patient-centered decision making. We searched Medline from 2000 to 2014 for English-language studies with prospectively captured data on ≥100 fistulas. We assessed study quality and extracted data on study design, patient characteristics, and outcomes. After screening 2292 citations, 43 articles met our inclusion criteria (61 unique cohorts; n>11,374 fistulas). Median complication rates per 1000 patient days were as follows: 0.04 aneurysms (14 unique cohorts; n=1827 fistulas), 0.11 infections (16 cohorts; n>6439 fistulas), 0.05 steal events (15 cohorts; n>2543 fistulas), 0.24 thrombotic events (26 cohorts; n=4232 fistulas), and 0.03 venous hypertensive events (1 cohort; n=350 fistulas). Risk of bias was high in many studies and event rates were variable, thus we could not present pooled results. Studies generally did not report variables associated with fistula complications, patient comorbidities, vessel characteristics, surgeon experience, or nursing cannulation skill. Overall, we found marked variability in complication rates, partly due to poor quality studies, significant heterogeneity of study populations, and inconsistent definitions. There is an urgent need to standardize reporting of methods and definitions of vascular access complications in future clinical studies to better inform patient and provider decision making.

Keywords: arteriovenous fistula; chronic hemodialysis; epidemiology and outcomes.

Figure 1.

Studies reporting the incident rate for all types of infections per 1000 patient days. Dashed line refers to the median event rate per 1000 patient days. AVF-T, transposed arteriovenous fistula; buttonhole, all patients cannulated using a buttonhole technique; elderly, ≥65 years; rope ladder, all patients cannulated using a rope ladder technique; standard, no specific cohort followed.

Figure 2.

Studies reporting the incident rate for ischemic steal syndrome per 1000 patient days. Dashed line refers to the median event rate per 1000 patient days. AVF-T, transposed arteriovenous fistula; elderly, ≥65 years unless otherwise specified; endo AVF-T, fistula transposition of a deep vein through endoscopic procedure; lower arm, cohort made up of all lower arm fistulas; open AVF-T, fistula transposition of a deep vein through a long open incision; standard, no specific cohort followed; upper arm, cohort made up of all upper arm fistulas.

Figure 3.

Studies reporting the incident rate for thrombosis per 1000 patient days. Dashed line refers to the median event rate per 1000 patient days. AVF-T, transposed arteriovenous fistula; buttonhole, all patients cannulated using a buttonhole technique; DUS monitoring, duplex ultrasound monitoring of blood flow; DVPM, dynamic venous pressure monitoring; elderly, ≥65 years unless otherwise specified; infrared, patients received far infrared therapy 3 times weekly for a year; lower arm, cohort made up of all lower arm fistulas; NM, no monitoring (standard care); Qa surveillance, access blood flow monitoring; standard, no specific cohort followed; TUS surveillance, transonic ultrasound monitoring of blood flow; upper arm, cohort made up of all upper arm fistulas; VABFM, vascular access blood flow monitoring.