Two-Year Cumulative and Functional Patency after Creation of Endovascular Arteriovenous Hemodialysis Fistulae

PURPOSE

To assess 2-year cumulative and functional patency of endovascular arteriovenous fistulae (endoAVF) created with the WavelinQ device.

MATERIALS AND METHODS

Patients who had fistulae created at a single center from December 2019 to December 2020 were included in this retrospective study. Forty-three patients underwent endoAVF creation (22 females, 21 males). Data collected included patient demographics, location of fistula creation, interventions performed, and brachial artery flow before and after creation. Two-year cumulative and functional patency rates were assessed with Kaplan-Meier method, and variables that affected patency and maturation were examined using Cox proportional hazards model.

RESULTS

Technical success was 95% (41/43), and in 4 patients, the fistula did not mature for dialysis use (9.7%). For the remaining 37 patients with endoAVF maturation, 25 had ulnar-ulnar fistulae, 10 had radial-radial fistulae, and 2 had interosseous artery-vein fistulae. Mean maturity time was 73 days, and brachial artery flow of >886 mL/min was predictive of maturation. Mean tunneled dialysis catheter removal time was 133 days. Number of interventions per patient-year was 0.38, where 8 were maturation procedures (5 vein elevations/transpositions and 3 coil embolizations) and 21 were maintenance angioplasties. Two-year cumulative/secondary and functional patency rates were 89.4% and 92.1%, respectively, with a mean follow-up of 665.7 days. Examined variables did not impact cumulative or functional patency. One adverse event was migration of coil to the heart, which was successfully retrieved at time of procedure.

CONCLUSIONS

Two-year patency of 89.4% and functional patency of 92.1% were observed after endoAVF creation with WavelinQ device.

Adapting a Dialysis Service for Delivery of Percutaneous Arteriovenous Fistulas

The percutaneous arteriovenous fistula (pAVF) is an exciting and novel addition to the vascular access options available to patients with end-stage kidney disease who require dialysis. Early clinical results have been promising, with high rates of maturation and low rates of reintervention. To successfully adapt an existing hemodialysis service to include the provision of pAVF formation, it is essential to identify and align the interests of key clinical and nonclinical stakeholders. Only through strong collaboration can the service be supported. The authors provide a comprehensive overview of the planning fundamentals required, including the referral pathway, screening and clinical assessment, and practical procedural elements and considerations, as well as follow-up requirements such as cannulation, fistula surveillance, and maintenance. Key staffing requirements are highlighted, including those pertaining to vascular US screening and dialysis nurse training. A broad and structured planning approach ensures that the entire network of key stakeholder interests is included and provides a strong foundation for a compelling business plan to attract the necessary funding and managerial support for the service. The authors present a systematic framework of the essential considerations necessary to facilitate the planning, funding, and ultimately delivery of a successful pAVF service. Online supplemental material is available for this article. ^©RSNA, 2022.

Percutaneous Hemodialysis Fistula Creation

Two devices have been recently introduced to European Union and North American clinical practice that allow for percutaneous creation of autogenous hemodialysis fistulas (pAVF). Although there are similarities between the devices, there are many differences. Adoption of either or both technologies by an interventionalist may be determined by the individual's comfort with the device. Importantly, current and future outcomes will shape acceptance and use of these devices. This review focuses on the similarities and differences of each device, the procedures, published outcomes to date and their interpretation and other clinical considerations towards initiation of a successful pAVF program.

Endovascular arteriovenous fistulas- are they the answer we haven't been looking for?

INTRODUCTION

Surgically created arteriovenous fistulas are the accepted gold standard for the establishment of hemodialysis access in patients requiring dialysis. However, primary and maturation failures may limit their usage. Recent advances in endovascular technology have resulted in the creation of devices for endovascular arteriovenous fistula formation. These devices may offer an additional or alternative approach to fistula formation in patients with end-stage kidney disease.

AREAS COVERED

This review describes the limitations of surgical arteriovenous fistulas and the endovascular devices currently available. The review covers initial trial data and subsequent studies examining their use.

EXPERT OPINION

Early results achieved with endovascular fistula formation are encouraging. Current limitations of this technology include anatomic suitability and a high rate of re-interventions required to establish maturity. Greater uptake of the technology will also require a review of long-term outcomes in larger patient cohorts.