Endovascular Management of

Nonmaturing Fistulae
Dr. Akhmadu Muradi, PhD, SpB(K)V
Division of Vascular and Endovascular Surgery
Department of Surgery, FMUI/Dr Cipto Mangunkusumo Hospital
Jakarta
InaVasc Makassar 2017
 Introduction
 The autogenous arteriovenous fistula is the preferred method of
vascular access for dialysis.

 fistulae require fewer interventions to maintain patency, have a

lower rate of thrombosis, and have longer access lifespans

 However, a substantial limitation of dialysis fistulae is their high

primary failure rate

 Various studies have shown that between 30% and 70% of

fistulae are never able to be used for a single successful
session of dialysis.
 What Defines a “Nonmaturing” Fistula?
 Accesses that, despite appropriate interventions, are unable to
be used for dialysis within 3 months of formation

 K-DOQI “rules of 6” for mature fistula:

 Able to support blood flow of 600 mL/min,
 Located less than 6 mm from the skin
 Measure greater than 6 mm in diameter
 A relatively straight segment at least 6 cm in length for cannulation
 Causes and Epidemiology of Nonmaturing
Fistulae
 Following fistula formation, the anastomosed vein
experiences a sudden increase in shear stress and
blood pressure result in dilatation of the vein and
remodeling of the vessel wall.

 In the setting of poor vessel elasticity, flow limiting

stenoses, or dissipation of flow by accessory or
collateral veins, this maturation process does not occur.
 Anatomical Causes of Nonmaturation
 Generally classified as :
 Inflow problems (native arterial disease, arteriovenous
anastomotic stenosis, and juxta-anastomotic stenosis) or
 Outflow problems (proximal venous stenosis or collateral veins).
 The most common identified lesion in non maturing fistula :
 Venous stenosis (60 %)
 Accessory or collateral veins (20 %)
 Veins that are too deep to allow for palpation guided cannulation (5
%)
 Anatomical Causes of Nonmaturation
Radiocephalic Fistula

 K-DOQI-preferred first choice for dialysis access owing to the

lower rates of steal syndrome and the fact that a more proximal
fistula can still be created should the radiocephalic fistula fail.

 Have the highest rate of primary failure, up to two-thirds will

never be suitable for dialysis.

 The most common cause of failure is venous stenosis, and the

most common location is a Juxta anastomotic stenosis
 Anatomical Causes of Nonmaturation
Brachiocephalic Fistula

 Pros: have higher patency and faster maturation rates than

radiocephalic fistulae

 Cons: higher rate of steal syndrome and preclusion of

subsequent distal forearm fistula formation

 Venous stenosis is also the principal culprit for nonmaturation

of brachiocephalic fistulae.
 Diagnostic Tools for Nonmaturing Fistulae
Physical Examination
 4-6 weeks after creation
 Inflow problems (juxta-anastomotic stenosis)
 The normal continuous thrill palpated at the anastomosis is
replaced with a strongly pulsatile flow; moreover, as one traces the
fistula, there is an immediate loss of pulsatility distal to the juxta-
anastomotic stenosis, with typically only a weak pulse palpable.

 Outflow problems (accessory vein)

 The continuous thrill at the arterial anastomosis should be
completely suppressed when the downstream fistula is manually
occluded. If flow at the anastomosis persists, this implies at least 1
accessory vein between the anastomosis and the level of fistula
occlusion
 Diagnostic Tools for Nonmaturing Fistulae
Ultrasound

 KDOQI “rules of 6”
 Ultrasound at 2 weeks is predictive of blood flow rates
and diameters at 6 weeks and may be a useful tool for
screening patients who may warrant interventions at an
early time point
 Interventions for Nonmaturing Fistulae
Juxta-Anastomotic Venous Stenosis

Angiography and angioplasty of juxta-anastomotic stenosis in a brachiocephalic fistula

Retrograde puncture of the cephalic vein with angiography performed in the upstream
brachial artery demonstrates severe juxta-anastomotic stenosis (arrow), with near-
complete obturation of the lumen by the 5 Fr catheter.
 Interventions for Nonmaturing Fistulae
Juxta-Anastomotic Venous Stenosis

Angioplasty was performed using a 6 mm " 2 cm balloon.

 Interventions for Nonmaturing Fistulae
Juxta-Anastomotic Venous Stenosis

Postangioplasty, there is significant improvement of blood flow, with no substantial

residual stenosis
 Interventions for Nonmaturing Fistulae

Accessory or Collateral Veins

 The conventional approach to treating accessory or collateral

veins is surgical ligation.

 From an endovascular perspective, coil embolization can

improve fistula maturation
 Interventions for Nonmaturing Fistulae
Accessory or Collateral Vein

Coil ligation of accessory draining veins

Patient with a nonmaturing brachiocephalic fistula who had previously undergone
accessory vein coil embolization returned to Interventional Radiology owing to persistent
failure to mature
 Interventions for Nonmaturing Fistulae
Accessory or Collateral Vein

After coil embolization of an additional accessory vein, there is improved flow through
the primary venous drainage pathway. Note that the coil masses were kept a sufficient
distance away from the body ofthe fistula to avoid the inflammatory reaction extending
into the fistula.
Interrupting rivaling access-flow with nonsurgical image
guided ligation (“IRANI” procedure)

Interrupting rivaling access-flow with nonsurgical image-guided ligation (“IRANI”

procedure). As an alternative to surgical ligation and coil embolization, image-guided
suture ligation can be performed in the angiography suite. A blunt-tipped needle is
advanced deep (A) and superficial (B) to the targeted accessory or collateral vein, and a
suture is passed through the cannula to encircle the vein. This procedure is performed
under ultrasound guidance
Interrupting rivaling access-flow with nonsurgical image
guided ligation (“IRANI” procedure)

A patient with a nonmaturing brachiocephalic fistula was found to have a large early
accessory vein (arrow)
Interrupting rivaling access-flow with nonsurgical image
guided ligation (“IRANI” procedure)

The accessory vein was successfully ligated, promoting flow through the cephalic vein.