Salvage of the nonfunctioning arteriovenous fistula

Two factors are necessary for an arteriovenous fistula (AVF) to be usable as dialysis access. It must have adequate blood flow, and it must have a size that will allow for cannulation. An AVF can remain patent in the face of relatively low blood flow. For effective dialysis, the AVF only has to deliver a blood flow that is marginally greater than the pump rate. Unfortunately, dialysis may not be technically possible in these cases with lower flow because the AVF does not mature sufficiently to a size adequate for cannulation. In this prospective observational series of 63 patients, failure of AVF development was the result of venous stenosis and/or the presence of accessory veins (venous side branches). The presence of these anomalies could be diagnosed by physical examination. After documentation by angiography, the patients were treated with angioplasty, venous ligation, or a combination of both. Three levels of venous ligation were performed depending on individual requirements: ligation of accessory veins (AVL), ligation of the median cubital vein, and temporary banding of the main fistula itself. The determining factor was the appearance of the fistula after each of the procedures was accomplished relative to potential for cannulation. Of these 63 patients with nonfunctional fistulae that ranged in age from 33 to 418 days, access was salvaged in 52 patients (82.5%). This included 9 of 12 patients who required repeat procedures. The results of this study validate angioplasty and AVL as therapy for the salvage of AVFs that fail to develop.