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 'Outcomes for 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".)
- Lee T, Ullah A, Allon M, et al. Decreased cumulative access survival in arteriovenous fistulas requiring interventions to promote maturation. Clin J Am Soc Nephrol 2011; 6:575.
- Vascular Access Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006; 48 Suppl 1:S248.
- Hemodialysis Adequacy 2006 Work Group. Clinical practice guidelines for hemodialysis adequacy, update 2006. Am J Kidney Dis 2006; 48 Suppl 1:S2.
- NKF-K/DOQI Clinical Practice Guidelines For Vascular Access. Clinical Practice Guideline 4: Detection of access dysfunction: monitoring, surveillance, and diagnostic testing. Am J Kidney Dis 2006; 48(Suppl 1):S248.
- Ethier JH, Lindsay RM, Barre PE, et al. Clinical practice guidelines for vascular access. Canadian Society pf Nephrology. J Am Soc Nephrol 1999; 10 Suppl 13:S297.
- Beathard GA. Angioplasty for arteriovenous grafts and fistulae. Semin Nephrol 2002; 22:202.
- Beathard GA, Settle SM, Shields MW. Salvage of the nonfunctioning arteriovenous fistula. Am J Kidney Dis 1999; 33:910.
- Falk A, Teodorescu V, Lou WY, et al. Treatment of "swing point stenoses" in hemodialysis arteriovenous fistulae. Clin Nephrol 2003; 60:35.
- Badero OJ, Salifu MO, Wasse H, Work J. Frequency of swing-segment stenosis in referred dialysis patients with angiographically documented lesions. Am J Kidney Dis 2008; 51:93.
- Rajan DK, Clark TW, Patel NK, et al. Prevalence and treatment of cephalic arch stenosis in dysfunctional autogenous hemodialysis fistulas. J Vasc Interv Radiol 2003; 14:567.
- Jaberi A, Schwartz D, Marticorena R, et al. Risk factors for the development of cephalic arch stenosis. J Vasc Access 2007; 8:287.
- Hammes M, Funaki B, Coe FL. Cephalic arch stenosis in patients with fistula access for hemodialysis: relationship to diabetes and thrombosis. Hemodial Int 2008; 12:85.
- Jennings WC, Miller GA, Coburn MZ, et al. Vascular access flow reduction for arteriovenous fistula salvage in symptomatic patients with central venous occlusion. J Vasc Access 2012; 13:157.
- Miller GA, Friedman A, Khariton A, et al. Access flow reduction and recurrent symptomatic cephalic arch stenosis in brachiocephalic hemodialysis arteriovenous fistulas. J Vasc Access 2010; 11:281.
- Ene-Iordache B, Remuzzi A. Disturbed flow in radial-cephalic arteriovenous fistulae for haemodialysis: low and oscillating shear stress locates the sites of stenosis. Nephrol Dial Transplant 2012; 27:358.
- Manninen HI, Kaukanen E, Mäkinen K, Karhapää P. Endovascular salvage of nonmaturing autogenous hemodialysis fistulas: comparison with endovascular therapy of failing mature fistulas. J Vasc Interv Radiol 2008; 19:870.
- Falk A. Maintenance and salvage of arteriovenous fistulas. J Vasc Interv Radiol 2006; 17:807.
- Turmel-Rodrigues L, Mouton A, Birmelé B, et al. Salvage of immature forearm fistulas for haemodialysis by interventional radiology. Nephrol Dial Transplant 2001; 16:2365.
- Beathard GA, Arnold P, Jackson J, et al. Aggressive treatment of early fistula failure. Kidney Int 2003; 64:1487.
- Nassar GM, Nguyen B, Rhee E, Achkar K. Endovascular treatment of the "failing to mature" arteriovenous fistula. Clin J Am Soc Nephrol 2006; 1:275.
- Clark TW, Cohen RA, Kwak A, et al. Salvage of nonmaturing native fistulas by using angioplasty. Radiology 2007; 242:286.
- Shin SW, Do YS, Choo SW, et al. Salvage of immature arteriovenous fistulas with percutaneous transluminal angioplasty. Cardiovasc Intervent Radiol 2005; 28:434.
- Clark TW, Hirsch DA, Jindal KJ, et al. Outcome and prognostic factors of restenosis after percutaneous treatment of native hemodialysis fistulas. J Vasc Interv Radiol 2002; 13:51.
- Turmel-Rodrigues L, Pengloan J, Rodrigue H, et al. Treatment of failed native arteriovenous fistulae for hemodialysis by interventional radiology. Kidney Int 2000; 57:1124.
- Sivanesan S, How TV, Bakran A. Sites of stenosis in AV fistulae for haemodialysis access. Nephrol Dial Transplant 1999; 14:118.
- Beaulieu MC, Gabana C, Rose C, et al. Stenosis at the area of transposition - an under-recognized complication of transposed brachiobasilic fistulas. J Vasc Access 2007; 8:268.
- Torina PJ, Westheimer EF, Schanzer HR. Brachial vein transposition arteriovenous fistula: is it an acceptable option for chronic dialysis vascular access? J Vasc Access 2008; 9:39.
- Kian K, Unger SW, Mishler R, et al. Role of surgical intervention for cephalic arch stenosis in the "fistula first" era. Semin Dial 2008; 21:93.
- Kian K, Asif A. Cephalic arch stenosis. Semin Dial 2008; 21:78.
- Turmel-Rodrigues L, Pengloan J, Baudin S, et al. Treatment of stenosis and thrombosis in haemodialysis fistulas and grafts by interventional radiology. Nephrol Dial Transplant 2000; 15:2029.
- Agarwal AK, Patel BM, Haddad NJ. Central vein stenosis: a nephrologist's perspective. Semin Dial 2007; 20:53.
- MacRae JM, Ahmed A, Johnson N, et al. Central vein stenosis: a common problem in patients on hemodialysis. ASAIO J 2005; 51:77.
- Glass C, Dugan M, Gillespie D, et al. Costoclavicular venous decompression in patients with threatened arteriovenous hemodialysis access. Ann Vasc Surg 2011; 25:640.
- Illig KA, Gabbard W, Calero A, et al. Aggressive Costoclavicular Junction Decompression in Patients with Threatened AV Access. Ann Vasc Surg 2015; 29:698.
- Asif A, Gadalean FN, Merrill D, et al. Inflow stenosis in arteriovenous fistulas and grafts: a multicenter, prospective study. Kidney Int 2005; 67:1986.
- Romero A, Polo JR, Garcia Morato E, et al. Salvage of angioaccess after late thrombosis of radiocephalic fistulas for hemodialysis. Int Surg 1986; 71:122.
- Beathard G. Complications of vascular access. In: Complications of Dialysis, Lameire N, Mehta RL (Eds), Marcel Dekker, New York 2000. p.1.
- Haage P, Vorwerk D, Wildberger JE, et al. Percutaneous treatment of thrombosed primary arteriovenous hemodialysis access fistulae. Kidney Int 2000; 57:1169.
- Chang CJ, Ko YS, Ko PJ, et al. Thrombosed arteriovenous fistula for hemodialysis access is characterized by a marked inflammatory activity. Kidney Int 2005; 68:1312.
- Ahmad I. Salvage of arteriovenous fistula by angioplasty of collateral veins establishing a new channel. J Vasc Access 2007; 8:123.
- Beathard GA, Litchfield T, Physician Operators Forum of RMS Lifeline, Inc. Effectiveness and safety of dialysis vascular access procedures performed by interventional nephrologists. Kidney Int 2004; 66:1622.
- Schon D, Mishler R. Salvage of occluded autologous arteriovenous fistulae. Am J Kidney Dis 2000; 36:804.
- Schon D, Mishler R. Pharmacomechanical thrombolysis of natural vein fistulas: reduced dose of TPA and long-term follow-up. Semin Dial 2003; 16:272.
- Huang HL, Chen CC, Chang SH, et al. Combination of duplex ultrasound-guided manual declotting and percutaneous transluminal angioplasty in thrombosed native dialysis fistulas. Ren Fail 2005; 27:713.
- Shatsky JB, Berns JS, Clark TW, et al. Single-center experience with the Arrow-Trerotola Percutaneous Thrombectomy Device in the management of thrombosed native dialysis fistulas. J Vasc Interv Radiol 2005; 16:1605.
- Poulain F, Raynaud A, Bourquelot P, et al. Local thrombolysis and thromboaspiration in the treatment of acutely thrombosed arteriovenous hemodialysis fistulas. Cardiovasc Intervent Radiol 1991; 14:98.
- Jain G, Maya ID, Allon M. Outcomes of percutaneous mechanical thrombectomy of arteriovenous fistulas in hemodialysis patients. Semin Dial 2008; 21:581.
- Palmer RM, Cull DL, Kalbaugh C, et al. Is surgical thrombectomy to salvage failed autogenous arteriovenous fistulae worthwhile? Am Surg 2006; 72:1231.
- Ponikvar R. Surgical salvage of thrombosed arteriovenous fistulas and grafts. Ther Apher Dial 2005; 9:245.
- Lipari G, Tessitore N, Poli A, et al. Outcomes of surgical revision of stenosed and thrombosed forearm arteriovenous fistulae for haemodialysis. Nephrol Dial Transplant 2007; 22:2605.
- Tordoir JH, Rooyens P, Dammers R, et al. Prospective evaluation of failure modes in autogenous radiocephalic wrist access for haemodialysis. Nephrol Dial Transplant 2003; 18:378.
- Ponce P, Cruz J, Ferreira A, et al. A prospective study on incidence of bacterial infections in portuguese dialysis units. Nephron Clin Pract 2007; 107:c133.
- Rajan DK, Patel NH, Valji K, et al. Quality improvement guidelines for percutaneous management of acute limb ischemia. J Vasc Interv Radiol 2005; 16:585.
- Won JH, Bista AB, Bae JI, et al. A venotomy and manual propulsion technique to treat native arteriovenous fistulas occluded by thrombi. AJR Am J Roentgenol 2012; 198:460.
- Cull DL, Washer JD, Carsten CG, et al. Description and outcomes of a simple surgical technique to treat thrombosed autogenous accesses. J Vasc Surg 2012; 56:861.
- Fysaraki M, Samonis G, Valachis A, et al. Incidence, clinical, microbiological features and outcome of bloodstream infections in patients undergoing hemodialysis. Int J Med Sci 2013; 10:1632.
- NKF-K/DOQI Clinical Practice Guidelines For Vascular Access. Clinical Practice Guideline 5: Treatment of fistula complications. Am J Kidney Dis 2006; 48(Suppl 1):S248.
- Schilling JJ, Eiser AR, Slifkin RF, et al. The role of thrombolysis in hemodialysis access occlusion. Am J Kidney Dis 1987; 10:92.
- Beathard GA. Mechanical versus pharmacomechanical thrombolysis for the treatment of thrombosed dialysis access grafts. Kidney Int 1994; 45:1401.
- Trerotola SO, Johnson MS, Shah H, et al. Incidence and management of arterial emboli from hemodialysis graft surgical thrombectomy. J Vasc Interv Radiol 1997; 8:557.
- Kinney TB, Valji K, Rose SC, et al. Pulmonary embolism from pulse-spray pharmacomechanical thrombolysis of clotted hemodialysis grafts: urokinase versus heparinized saline. J Vasc Interv Radiol 2000; 11:1143.
- Bentaarit B, Duval AM, Maraval A, et al. Paradoxical embolism following thromboaspiration of an arteriovenous fistula thrombosis: a case report. J Med Case Rep 2010; 4:345.
- Swan TL, Smyth SH, Ruffenach SJ, et al. Pulmonary embolism following hemodialysis access thrombolysis/thrombectomy. J Vasc Interv Radiol 1995; 6:683.
- Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984; 59:17.
- Ward R, Jones D, Haponik EF. Paradoxical embolism. An underrecognized problem. Chest 1995; 108:549.
- Yigla M, Abassi Z, Reisner SA, Nakhoul F. Pulmonary hypertension in hemodialysis patients: an unrecognized threat. Semin Dial 2006; 19:353.
- Briefel GR, Regan F, Petronis JD. Cerebral embolism after mechanical thrombolysis of a clotted hemodialysis access. Am J Kidney Dis 1999; 34:341.
- Bent CL, Sahni VA, Matson MB. The radiological management of the thrombosed arteriovenous dialysis fistula. Clin Radiol 2011; 66:1.
- Kim DH, Goo DE, Yang SB, et al. Endovascular management of immediate procedure-related complications of failed hemodialysis access recanalization. Korean J Radiol 2005; 6:185.
- Vesely TM. Complications related to percutaneous thrombectomy of hemodialysis grafts. J Vasc Access 2002; 3:49.
- 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