While the long-term viability of fistulas that have been flagged as nonmaturing has been called into question, the early identification of suboptimal maturation and thus the treatment of the AVF may result in a functional fistula in the vast maturity of patients. Two prospective studies demonstrate that immature AVFs may be salvaged by endovascular management in 83% to 87% of cases [95,99]. A study by Clark et al [106] reported a paradigm where native fistulas were assessed with physical examination at 4 to 6 weeks by a surgical or nephrology team member. A single attempt at cannulation was then performed. If the fistula was clearly visible and easily cannulated, no further evaluation was performed, and the fistula continued its subsequent maturation until deemed suitable for use, routinely at 3 months postcreation. If a native fistula was not deemed to have matured sufficiently at 3 months, the patient was referred to interventional radiology for diagnostic fistulography with an attempt at percutaneous salvage. Clark et al [106] reported that percutaneous angioplasty facilitated the salvage of 75 of 85 (88%) of the studied native fistulas that were flagged as failing to mature. They achieved primary patency rates of 45% (6 months) and 34% (12 months). Of note, their reported secondary interventions included angioplasty, stent placement, as well as thrombectomy, which were reported to help augment the patency rate up to 79% at 6 months with long-term rates at 12 months of 75%, and at 18 months to 63% [106]. Surgical Consultation Opinions and research diverge on the causes of nonmaturation. Turmel-Rodrigues et al [97] purports that an AVF that fails to mature is precipitated by a coexisting venous stenosis in 100% of patients assessed with diagnostic fistulography. Conversely, Beathard et al [96] touts that a lack of maturation is routinely due to a competing venous collateral.
Dialysis Fistula Malfunction. While the long-term viability of fistulas that have been flagged as nonmaturing has been called into question, the early identification of suboptimal maturation and thus the treatment of the AVF may result in a functional fistula in the vast maturity of patients. Two prospective studies demonstrate that immature AVFs may be salvaged by endovascular management in 83% to 87% of cases [95,99]. A study by Clark et al [106] reported a paradigm where native fistulas were assessed with physical examination at 4 to 6 weeks by a surgical or nephrology team member. A single attempt at cannulation was then performed. If the fistula was clearly visible and easily cannulated, no further evaluation was performed, and the fistula continued its subsequent maturation until deemed suitable for use, routinely at 3 months postcreation. If a native fistula was not deemed to have matured sufficiently at 3 months, the patient was referred to interventional radiology for diagnostic fistulography with an attempt at percutaneous salvage. Clark et al [106] reported that percutaneous angioplasty facilitated the salvage of 75 of 85 (88%) of the studied native fistulas that were flagged as failing to mature. They achieved primary patency rates of 45% (6 months) and 34% (12 months). Of note, their reported secondary interventions included angioplasty, stent placement, as well as thrombectomy, which were reported to help augment the patency rate up to 79% at 6 months with long-term rates at 12 months of 75%, and at 18 months to 63% [106]. Surgical Consultation Opinions and research diverge on the causes of nonmaturation. Turmel-Rodrigues et al [97] purports that an AVF that fails to mature is precipitated by a coexisting venous stenosis in 100% of patients assessed with diagnostic fistulography. Conversely, Beathard et al [96] touts that a lack of maturation is routinely due to a competing venous collateral.