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
- David L Cull, MD
David L Cull, MD
- Section Editor — Arterial and Venous Access
- Clinical Professor, Department of Surgery
- University of South Carolina School of Medicine
- 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
Late failure of a hemodialysis arteriovenous (AV) fistula is defined as the inability to use a matured AV fistula after at least three months of normal usage. Although the mature hemodialysis AV 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 AV fistula are vascular stenotic lesions. These lesions manifest as decreased flow leading to inadequate dialysis and eventually thrombosis.
Failure of the mature AV fistula and management will be reviewed here. Primary failure of the newly created hemodialysis arteriovenous fistula is reviewed separately, as are other types of AV fistula dysfunction, such as hemodialysis ischemic syndrome, aneurysm formation, infection, and excess flow leading to congestive heart failure. (See "Primary failure of the hemodialysis arteriovenous fistula" and "Nonthrombotic complications of arteriovenous hemodialysis access".)
The risk factors associated with failure of a hemodialysis arteriovenous (AV) fistula are reviewed separately. In addition, it is not surprising that AV fistulas 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 AV fistula failure' and "Primary failure of the hemodialysis arteriovenous fistula", section on 'Fistula salvage'.)
MONITORING THE MATURE AV FISTULA
Failure of the mature hemodialysis arteriovenous (AV) fistula 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 AV 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 AV FISTULA
- STENOTIC VASCULAR LESIONS
- Swing-point stenosis
- - Juxta-anastomotic stenosis
- - Brachial-basilic angle of transposition stenosis
- - Cephalic arch
- Central vein stenosis
- Arterial stenosis
- Treatment of vascular stenosis
- THROMBOSED FISTULA
- Treatment of thrombosis
- - Contraindications to attempted salvage
- Right-to-left shunt
- Chronic occlusion
- Excess thrombus burden
- - Complications of thrombectomy
- SUMMARY AND RECOMMENDATIONS