Predictors of maturation failure in arteriovenous dialysis access

Failure of arteriovenous fistula (AVF) maturation results in unnecessary patient risk and resource waste. We sought to identify potentially addressable risk factors for fistula failure to mature (FTM) to cannulation readiness.

We conducted a single-institution retrospective review of patients undergoing primary AVF creation from 2015 to 2021. Fistula configuration was based on bedside preoperative ultrasound examinations. Cannulation readiness (maturation) was determined primarily by surgeon physical examination. Demographics, comorbidities, and follow-up procedures (balloon-assisted maturation [BAM], surgical-assisted maturation [SAM] [includes branch ligation and unplanned superficialization], and steal interventions) were recorded. Univariate and multivariate analyses (univariate P < .1) were performed exploring associations between patient/surgical factors and FTM within 1 year.

We included 363 patients underwent creation of a new AVF. Fourteen patients (3.7%) were lost to follow-up before maturation or abandonment and were excluded from analysis. Of those remaining, 80 (23%) were never used successfully. Death within 1 year, peripheral arterial disease, and median antecubital vein (MACV) fistula were associated with FTM on univariate and multivariate analysis. Nearly one-half of MACV fistulas (42%) failed to mature. BAM was successful in 29 of 48 cases (60%) but was associated with fistula nonmaturation on univariate and multivariate analyses. Neither age, sex, comorbidities other than peripheral arterial disease, prior AV access, nor radiocephalic fistula (RCAVF) were associated with FTM. Female and older patients were much less likely to receive a RCAVF.

More than one-fifth of AVFs did not achieve cannulation readiness. Improved patient and procedure selection, avoiding the use of the MACV, and construction in those at high risk of death within 1 year may help to improve maturation rates. RCAVF can be expected to mature in well-selected patients. BAM is associated with maturation in more than one-half of cases and should be considered in nonmaturing fistulas.