Small venous tributaries or accessory veins are thought to shunt blood flow away from the venous outflow, thus impairing maturation. However, the accepted range of etiologies for nonmaturation of an AVF include a stenosis, lack of vein and artery dilation secondary to intimal hyperplasia, the presence of scarring in the outflow vein, and atherosclerotic disease, large accessory veins, an AVF vein that is too deep to cannulate, among other factors [107]. A hemodynamically significant stenosis results in smaller diameters and thus reduced blood flows, a finding which was significant in the Hemodialysis Fistula Maturation (HFM) in their initial studied model [107]. Of note, in this prospective study, there was no significant relationship of fistula nonmaturation with the presence of an accessory vein. However, authors note that a large accessory vein may divert blood flow to a degree that warrants embolization by an interventional radiologist or ligation by a vascular surgeon [103]. In a study by Mufty et al [101] a proactive surveillance program was developed to identify and preemptively manage nonmaturing AVFs. In this study, 164 patients were seen at an outpatient clinic at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months postoperatively, by a dialysis nurse and vascular surgeon. AVF maturation marked in part by patency and functionality were assessed by physical examination as well as US. When there was clinical suspicion for a stenosis, further diagnostic duplex US and/or fistulography was performed. When indicated, a salvage intervention was then performed. Similarly, when a percutaneous salvage procedure was not deemed feasible, creation of a new AVF by the vascular surgeon ensued. Dialysis Fistula Malfunction surgical techniques to facilitate postoperative maturation.
Dialysis Fistula Malfunction. Small venous tributaries or accessory veins are thought to shunt blood flow away from the venous outflow, thus impairing maturation. However, the accepted range of etiologies for nonmaturation of an AVF include a stenosis, lack of vein and artery dilation secondary to intimal hyperplasia, the presence of scarring in the outflow vein, and atherosclerotic disease, large accessory veins, an AVF vein that is too deep to cannulate, among other factors [107]. A hemodynamically significant stenosis results in smaller diameters and thus reduced blood flows, a finding which was significant in the Hemodialysis Fistula Maturation (HFM) in their initial studied model [107]. Of note, in this prospective study, there was no significant relationship of fistula nonmaturation with the presence of an accessory vein. However, authors note that a large accessory vein may divert blood flow to a degree that warrants embolization by an interventional radiologist or ligation by a vascular surgeon [103]. In a study by Mufty et al [101] a proactive surveillance program was developed to identify and preemptively manage nonmaturing AVFs. In this study, 164 patients were seen at an outpatient clinic at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months postoperatively, by a dialysis nurse and vascular surgeon. AVF maturation marked in part by patency and functionality were assessed by physical examination as well as US. When there was clinical suspicion for a stenosis, further diagnostic duplex US and/or fistulography was performed. When indicated, a salvage intervention was then performed. Similarly, when a percutaneous salvage procedure was not deemed feasible, creation of a new AVF by the vascular surgeon ensued. Dialysis Fistula Malfunction surgical techniques to facilitate postoperative maturation.