Failure of the mature hemodialysis arteriovenous fistula
- Gerald A Beathard, MD, PhD
Gerald A Beathard, MD, PhD
- Clinical Professor
- University of Texas Medical Branch
- Section Editors
- Jeffrey S Berns, MD
Jeffrey S Berns, MD
- Editor-in-Chief — Nephrology
- Section Editor — Dialysis
- Professor of Medicine
- Perelman School of Medicine at the University of Pennsylvania
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery
- University of South Carolina School of Medicine Greenville
Late failure of a hemodialysis arteriovenous fistula (AVF) is defined as the inability to use a matured AVF after at least three months of normal usage. Although the mature hemodialysis arteriovenous fistula is associated with fewer complications compared with other types of vascular access, when problems occur, they need to be managed effectively. The main causes of failure in a mature hemodialysis arteriovenous fistula are vascular stenotic lesions. These lesions manifest as decreased flow leading to inadequate dialysis and eventually thrombosis.
Failure of the mature AVF and management will be reviewed here. Primary failure of the newly created hemodialysis arteriovenous fistula is reviewed separately as are other types of AVF dysfunction, such as hemodialysis ischemic syndrome, aneurysm formation, infection, and excess flow leading to congestive heart failure are discussed separately. (See "Primary failure of the hemodialysis arteriovenous fistula" and "Nonthrombotic complications of chronic hemodialysis arteriovenous vascular access".)
The risk factors associated with failure of a hemodialysis arteriovenous fistula are reviewed separately. In addition, it is not surprising that AVFs requiring intervention prior to maturation are more likely to fail in the long term, even if they appear to mature and are functional following intervention . (See "Creating an arteriovenous fistula for hemodialysis", section on 'Risk factors for AVF failure' and "Primary failure of the hemodialysis arteriovenous fistula", section on 'Fistula salvage'.)
MONITORING THE MATURE AVF
Failure of the mature hemodialysis arteriovenous fistula (AVF) is frequently suspected during monitoring designed to detect stenosis so that it can be identified and treated prior to thrombosis, usually on the basis of physical examination findings, flow measurements, or duplex ultrasound [2,3]. Lesions associated with the mature hemodialysis arteriovenous fistulas can include arterial or venous stenosis (preexisting or acquired), and collateral veins. These are described in more detail elsewhere. (See "Primary failure of the hemodialysis arteriovenous fistula", section on 'Associated lesions'.)
Findings on physical examination associated with vascular stenotic lesions or thrombosis are listed briefly below, and these, along with other methods for monitoring and surveillance of fistulas, are discussed in detail elsewhere. (See "Examination of the mature hemodialysis arteriovenous fistula" and "Clinical monitoring and surveillance of the mature hemodialysis arteriovenous fistula".)
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- RISK FACTORS
- MONITORING THE MATURE AVF
- Stenotic vascular lesions
- - Venous stenosis
- Sites of predilection
- - Swing points
- - Cephalic arch
- - Vein valves
- - Arterial stenosis
- Thrombosed fistula
- - Contraindications to attempted salvage
- - Salvage
- TREATMENT COMPLICATIONS
- SUMMARY AND RECOMMENDATIONS