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Prediction of Arteriovenous Fistula Maturation

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Dr Alfred K Cheung, Salt Lake City, USA    28 December 2018

  • Causes of arteriovenous fistula (AVF) biological maturation failure are not elucidated. Postoperative stenosis plays a role, but relative contribution is uncertain. Innate ability of vessel to sustain dilation is likely very important, but poorly studied.
  • NIDDK Dialysis Access Consortium (DAC) Fistula Trial: It involved 877 patients undergoing AVF creation. Clopidogrel (75 mg QD vs. placebo) decreased thrombosis in 6 weeks (12.2% vs. 19.5%; RR = 0.63; p = 0.018). There was no effect on AVF clinical maturation failure in 5 months (61.8% vs. 59.5%; RR = 1.05; p = 0.40). It highlights the importance of understanding prediction and mechanisms of AVF maturation failure.
  • Pre-existing venous intimal hyperplasia has been shown to be nonsignificantly associated with unassisted clinical maturation failure.
  • Pre-existing intimal hyperplasia and postoperative stenosis in hemodialysis fistula maturation (HFM): Pre-existing intimal hyperplasia has been found to be common, but appeared to be inactive and not associated with postoperative stenosis or maturation failure. Postoperative stenosis has been found to be associated with maturation failure, but its relative contribution to maturation failure is unclear.
  • Patients with advanced CKD have poor vascular functions. Postoperative increases in AVF vein diameter and blood flow rate are associated with preoperative (underlying) brachial artery reactivity. The results inform biology of AVF maturation process, but are not strong predictors of maturation.
  • Future studies should focus on mediators as well as functional and structural wall properties that regulate ability of vessels to sustain dilation. Process of care is likely important determinant of clinical usability of AVF.

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