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Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 23-27

Salvage procedures for failing arteriovenous fistula: “An institutional experience”

1 Department of Urology and Renal Transplantation, JIPMER, Puducherry, India
2 Department of Nephrology, JIPMER, Puducherry, India

Date of Web Publication8-Mar-2019

Correspondence Address:
Dr. R Manikandan
Department of Urology and Renal Transplantation, JIPMER, Puducherry
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijves.ijves_50_18

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Introduction: Arteriovenous fistula (AVF) is lifeline for patients with end-stage renal disease. A fistula should be mature enough to support efficient hemodialysis. The most important requirement is adequate blood flow through the fistula. This goal is achieved in most AVF. Few fistulas do not mature, i.e., there is inadequate blood flow through the fistula. In this condition, we may close this improperly functioning fistula and create fistula at another site. Closure or ligation of inadequate, but uncomplicated fistula, is not the norm. Another less utilized and described option is to perform some auxiliary procedures to salvage the fistula when indicated. Auxiliary procedure may also be necessary in conditions such as steal syndrome and venous hypertension (VH). We present our experience with some of these auxiliary procedures. Aims: The aim of the study is to retrospective analysis of fistula salvage procedures for failing fistulae in our institution. Settings and Design: This was a retrospective, observational study. Subjects and Methods: A retrospective analysis of AVF was performed during the past 2 years that failed to mature and support an efficient hemodialysis. Another group of patients who had either steal syndrome or VH were also reviewed. Auxiliary procedures were done on all these patients with encouraging results. Results: In four patients, ligation of collateral was done. In one patient in whom there was a side-to-side arteriovenous anastomosis, ligation of distal venous segment was done to reverse VH. Another four patients with steal syndrome underwent partial occlusion of the vein near anastomotic site. In nine patients, endovascular dilation and/or stenting of stenosed segment of the vein was done. Conclusions: In patients with suboptimally working fistula, a lesion-specific auxiliary procedure can salvage and enhance their performance.

Keywords: Arteriovenous fistula, fistulogram, steal syndrome, tributary ligation, venous hypertension

How to cite this article:
Kumar S, Dutt UK, Singh S, Dorairajan L N, Manikandan R, Sampath E, Zaphu T. Salvage procedures for failing arteriovenous fistula: “An institutional experience”. Indian J Vasc Endovasc Surg 2019;6:23-7

How to cite this URL:
Kumar S, Dutt UK, Singh S, Dorairajan L N, Manikandan R, Sampath E, Zaphu T. Salvage procedures for failing arteriovenous fistula: “An institutional experience”. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2020 Jun 4];6:23-7. Available from:

  Introduction Top

An arteriovenous fistula (AVF) is created for efficient hemodialysis. The property of a mature AVF is (1) a dilated vascular channel with reasonably tough wall which can be cannulated with a large bore sheath. (2) Well-enough blood flow so that hemodialysis can be accomplished rapidly without substantially altering the hemodynamic physiology of the patient. As per the K/DOQI guidelines, an adequate AV fistula resides ~0.6 cm from the skin surface, has a flow >600 mL/min, and diameter >0.6 cm.[1] A properly created fistula attains these properties within 6–8 weeks. When blood flow to the venous segment of fistula is not enough, fistula fails to mature.

  Subjects and Methods Top

Data were collected retrospectively of those patients who had working AVF but not usable for hemodialysis and those patients who had some of the known complications such as steal syndrome and venous hypertension (VH), and auxiliary procedure was done to correct these complications and at the same time, fistula was also salvaged.

Group 1

In the first group of four patients, surgical ligation (SL) of tributary was done [Figure 1]. The age of patient ranged 17–57 years. These were radiocephalic (RC) AVF located at distal forearm or mid-forearm. All tributaries were identified by color Doppler ultrasonography and ligated by multiple incisions. There was a significant increase in blood flow after ligation of tributaries and fistula was reusable [Table 1].
Figure 1: Surgical ligation of tributaries. (a and b) tributaries of main draining vein identified and ligated. (c) Total four tributaries were ligated

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Table 1: Ligation of collaterals

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Group 2

A 65-year-old male in whom brachiocephalic (BC) AVF was done in the left hand in a side-to-side manner at elsewhere hospital. He presented 1 month later with persistent left upper-limb swelling and pain. Color Doppler was done that showed a patent fistula and multiple dilated venous channels but no any thrombus in the draining vein till subclavian vein. Fistula site was explored, and ligation of distal limb of the cephalic vein was done. The limb swelling disappeared after 24 h.

Group 3

A 50-year-old diabetic female underwent left RC-AVF for CKD. On the postoperative day 6, she returned back with pain in the left hand. A diagnosis of steal phenomena was made. Wound of fistula was explored, and a metallic clip was applied to partially occlude the cephalic vein near the anastomotic site. Her symptom improved immediately. Similarly, three more patients diagnosed to have steal syndrome due to excessive blood flow through the draining vein. Metallic clip was applied near the anastomotic site on venous side to partially occlude the venous return and symptoms improved.

Group 4

Due to underperforming RC-AVF, three patients underwent venography, and stenosis was found in the draining vein away from the site of the arteriovenous anastomosis. In two patients, it was at mid-forearm while in one patient, it was at the cubital fossa. In all three patients, endovascular dilation was done [Figure 3]. In one patient, there was recurrence of stenosis, and hence, a stent was placed at the site of stenosis [Figure 2]. Postprocedure, there was a significant increase in rate of blood flow, and fistula was usable [Table 2].
Figure 3: Balloon dilatation of stenosed arteriovenous fistula. (a) Stenosis in radiocephalic AV fistula. (b) Balloon deployed and inflated across the stenosis (Arrow). (c) After dilatation of stenosed segment of AV fistula

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Figure 2: Endovascular stenting of stenosed arteriovenous fistula. (a and b) Stenosis in draining vein of AV fistula (Arrow). (c) Balloon dilatation of stenosed segment. (d) Stent deployed. (e) Increased flow after stenting

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Table 2: Endovascular dilation and/or stenting

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Group 5

A 35-year-old female had persistent swelling of left upper limb since the creation of left BC-AVF at cubital fossa. She had earlier undergone placement of dialysis sheath in the subclavian vein. A diagnosis of subclavian vein/innominate vein thrombosis/narrowing was made which was confirmed on venography. Venoplasty resulted in subsidence of the limb swelling and later on, fistula became usable [Figure 4]. Five another patients having VH due to stenosis at subclevian or innominate vein caused by prolonged stay of dialysis sheath underwent venoplasty similarly, and all patients improved thereafter.
Figure 4: Innominate vein plasty. (a) Innominate vein stenosis. (b and c) Balloon dilatation of stenosed vein, (d) Dilated innominate vein

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  Results Top

We have done ligation of collateral branches in four patients. It was a RC-AVF at distal forearm in three patients and mid-forearm RC-AVF in one patient. Four, 5, 5, and 5 collaterals were ligated, respectively. Blood flow increased in all four patients sufficient enough to allow dialysis. Postligation blood flow was 385, 430, 455, and 440 ml/min. At the end of 1-month, blood flow was 450, 485, 520, and 510 ml/min, respectively, and dialysis was started at 21, 28, 19, and 26 days postoperatively. Patients are on follow-up (18, 14, 13, and 11 months) till now, and all fistulas are patent.

One patient with BC-AVF at cubital fossa had VH as it was a side-to-side arteriovenous anastomosis. Ligation of the distal segment of cephalic vein resulted in subsidence of limb swelling.

In four patients who were diagnosed to have steal syndrome, a metallic clip was applied to partially occlude the vein. The symptom improved in immediate postoperative period and a patient was canualated after mean of 48 days of fistula creation.

In another set of patients which were diagnosed to have stenosis of vein on fistulogram, dilation of stenosed segment by balloon was done. One patient had recurrence of stenosis after percutaneous transluminal angioplasty (PTA); hence, redilation with balloon followed by deployment of stent was done. Canulation of fistula for dialysis was done after 34, 28, and 75 days, respectively. All three patients are doing well.

Six patients were diagnosed to have VH due to either thrombosis or stenosis of upstream veins such as axillary/subclavian/innominate vein/superior vena cava, diagnosed by angiography. Venoplasty was done in all patients with successful outcome in four patients. One such patients required stent deployment. In one patient in whom venoplasty failed, ligation of fistula was done.

  Discussion Top

Etiopathogenesis and management

Maturation of AVF is necessary so that it can be used for hemodialysis. Adequacy of maturation is understood clinically if a fistula supports hemodialysis smoothly. Characteristic of a mature fistula is arterialization of the vein, good blood flow. According to KDQOI, an optimally mature fistula is indicated by the venous wall thickness of 0.6 mm, blood flow of 600 ml/min, and depth from the skin of 6 mm.[1] Fistula fails to mature due to various reasons such as stenosis at anastomotic site or in the vein near the anastomosis, intimal hyperplasia as a reaction to the altered hemodynamics in the vein and ultimately leading to narrowing of the vein, multiple collaterals in the draining vein leading to shunting of blood flow, and thus, not allowing arterialization of vein and poor blood flow in the main vein.[2],[3],[4]

In case of nonmaturation of fistula, we are left with either salvage of the fistula with various corrective measures as mentioned below or to create a new fistula at another site. Whenever possible, before embarking to create a new fistula at another site, every effort should be made to salvage the fistula as on sacrificing the fistula, we will be left with one less number of prospective fistula site because fistula is prone to stop working any time.

The modifiable factors which prevent maturation of fistula are collaterals to the main vein, stenosis of anastomotic site, or vein near the anastomosis. In literature, there are sparse reports of various methods to deal with these etiologies.

If the cause of nonmaturation of AVF is collaterals, it can be treated either by SL or angioembolization (AE). SL is simple, cheaper procedure and does not need use of contrast agent. Preoperative color duplex study is must detect the collaterals, its location, and to rule out other causes of nonmaturation of AVF such as stenosis of vein or anastomotic site. Ligation of collaterals leads to immediate as well as continued increase in blood flow in the main draining vein. Planken et al. have explored the role of preoperative MRA in patients of nonmatured AVF. He found that diameter of accessory vein >70% of cephalic vein specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV) of 100%, 80%, 100%, and 91% in predicting nonmaturation of AVF. Accessory vein ligation and dilation of venous stenosis have 89% salvage rate.[2]

Principle behind it can be easily understood by simple mechanical law of physics [Figure 5].
Figure 5: Mechanics of blood flow

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If the cause of nonmaturation is stenosis, the appropriate management is either PTA with or without stenting or surgical resection of the stenosis segment and either direct anastomosis of the two ends of vein or replacing the missing segment with venous graft. In this respect, most centers prefer PTA because salvage rate is superior.[5]

Some patients may develop steal syndrome which may be due to (1) patient-related factors such as preexisting small vessel disease due to diabetes/large and medium size vascular disease such as atherosclerosis and (2) faulty surgical technique such as large arteriotomy. Steal syndrome, on one hand, causes intractable pain in the limb and threatens the viability of limb distal to fistula while on another hand restricts cannulation of AVF as the steal syndrome may get aggravated. Steal syndrome can be mild and moderate-to-severe. Only moderate-to-severe steal syndrome needs treatment. Various treatment options are ligation, banding, distal revascularization-interval ligation (DRIL), revision using distal inflow (RUDI), and proximalization of the arterial inflow (PAI).[6],[7],[8],[9]

Another condition where cannulation of AVF is prohibited is VH. VH can develop due to: (1) thrombosis/stenosis of proximally situated venous channel and (2) dilation of venous channels distal to fistula which may occur in case of side-to-side anastomosis or collaterals of main vein communicating with distal venous channels. Most commonly, stenosis of central veins occurs due to the use of central venous dialysis sheath leading to endothelial injury, inflammation, and stenosis. Stenosis may preexist subclinically and becomes overt only after the creation of AVF. In the course of time, VH sometimes may disappear due to development collaterals. Patient presents with edema of the extremity, bluish discoloration, and depigmentation and in long-standing condition ulceration of digits.[10] A cases of VH should be evaluated by angiography to locate the site of stenosis either in advance or at the time of endovascular management.

Experience of other authors

Collateral and venous stenosis as cause of nonmaturation

Aly et al. have reported that interval tributary ligation is required in approximately 10% of AVF, the majority in RC fistulae. Interval tributary ligation is worthwhile in selected cases. Consideration should be given to early intervention and imaging before tributary ligation to establish if significant stenosis is also contributing to nonmaturation. Nonmaturation was defined as a nonfunctional vascular access at 2 months after creation. Preoperatively, detected accessory veins with a diameter >70% of the cephalic vein diameter had a sensitivity, specificity, PPV, and NPV of 80%, 100%, 100%, and 91%, respectively, for prediction of RC-AVF nonmaturation on the patient level. Accessory vein ligation and dilatation of venous stenosis resulted in an overall salvage success rate of 89%.[2] Long et al. concluded that anastomotic stenosis should be surgically as it has better primary patency rate than angioplasty. While in perianastomotic stenosis surgery and angioplasty have similar primary patency rate, but angioplasty group has higher reoperation rate.[3] According to Ahmed et al., embolization of collateral vein is also a viable option.[10] Asif et al. have advised that corrective measures in case of nonmaturing AVF should be adopted after 4–6 weeks as beyond this period probability of further remodeling of vein is dismal only in the presence of stenosis or collaterals.[11] Several authors have shown that juxta-anastomotic stenosis/thrombosis may be well managed with endovascular recanalization with or without the use of thrombolytic agents/angioplasty with or without stent which may be covered or uncovered.[4],[12],[13],[14],[15],[16],[17],[18],[19],[20] The success rate of various endovascular management reported in the literature ranges from 74% to 98%. Tessitore et al. observed that PTA has higher restenosis rate than surgical correction in case of juxta-anastomotic stenosis. However, the two procedures should be complementary to each other and choice between the two should depend on local expertise and technical availability.[5]

Falk et al. have observed that most of the juxta-anastomotic stenosis is in the swing zone, i.e., the segment of vein which is mobilized for anastomosis.[21],[22] Angioplasty may be done with standard noncompliant balloon, high-pressure balloon, and cutting balloon.[23]

Steal syndrome

Navy et al. have shown that coronary artery disease, hypertension (HTN), tobacco use, and female gender are the risk factors for the development of steal syndrome after AVF. SL, banding with ePTFE, DRIL, RUDI, and PAI which improve inflow are viable options. Banding has less success rate and frequently requires reintervention. Jackson and Charpentier have suggested that a quantitative reduction of blood flow by 50% as measured by ultrasound intraoperatively after applying a band of Gore-Tax secured with clip results in optimal outcome.[24] In our setting, simply a metallic clip was used to partially occlude the lumen of the juxta-anastomotic vein. Although the reduction in blood flow was not quantified by ultrasound, clinically, it was immediately appreciable decrease in the degree of thrill, and postoperatively, there was relief in the pain of steal syndrome. DRIL is effective but not uniformly having similar results. RUDI and PAI are other less invasive procedures.

[8] Shemesh et al. have advised the use of duplex ultrasound for optimal flow reduction in fistula and increasing the perfusion to the limb.[25] Odland et al. observed that plethysmography is a useful tool to guide the required narrowing of fistula to relieve the steal syndrome and salvage the shunt. The goal was a distal flow of 50 mmHg or digit to the brachial ratio of more than 0.6.[26] Meyer et al. advised that ligation should be done if the flow is <250 ml/min, and banding is done if flow is high.[27] In their study, Sueki et al. found that skin perfusion pressure is decreased in limb with AVF.[28] Jennings et al. advised that in patients with high risk of dialysis-associated steal syndrome, primary proximalization of inflow should be considered as a vascular access.[29] Korzets et al. found that DRIL is a safe and effective procedure for the treatment of steal syndrome and preoperative angiography, and evaluation of AVF by manual compression is crucial in determining the potential patient to get benefit by this surgery.[30]

Venous hypertension

Michel described a novel complication of pulmonary HTN after AVF which was successfully managed by SL of AVF.[31] Mittal et al. have described their experience of management of VH by means of SL, balloon dilatation with or without endovascular stent, and AE.[32] Jennings et al. have described precision banding procedure for access inflow reduction with the addition of real-time intravascular flow monitoring in 22 patients. Mean access flow was 1640 mL/min before banding decreased to 820 mL/min after banding. Swelling resolved promptly in 20 patients and was markedly improved in two individuals.[33]

  Conclusions Top

Creating a functional AVF is not an end of care by the surgeon. It requires continued surveillance so that it may meet the requisites for which it was fashioned. Fistulas which are not usable due to juxta-anastomotic stenosis, VH and steal syndrome are still amenable to salvage by various auxiliary procedures.

  References Top

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Planken RN, Duijm LE, Kessels AG, Leiner T, Kooman JP, Van Der Sande FM, et al. Accessory veins and radial-cephalic arteriovenous fistula non-maturation: A prospective analysis using contrast-enhanced magnetic resonance angiography. J Vasc Access 2007;8:281-6.  Back to cited text no. 2
Long B, Bruyere F, Lermusiaux P, Culty T, Boutin JM, Artru B, et al. Management of perianastomotic stenoses complicating vascular accesses for haemodialysis. Prog Urol 2008;18:462-9.  Back to cited text no. 3
Mercado C, Salman L, Krishnamurthy G, Choi K, Artikov S, Thomas I, et al. Early and late fistula failure. Clin Nephrol 2008;69:77-83.  Back to cited text no. 4
Tessitore N, Mansueto G, Lipari G, Bedogna V, Tardivo S, Baggio E, et al. Endovascular versus surgical preemptive repair of forearm arteriovenous fistula Juxta-anastomotic stenosis: Analysis of data collected prospectively from 1999 to 2004. Clin J Am Soc Nephrol 2006;1:448-54.  Back to cited text no. 5
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Ahmed O, Patel M, Ginsburg M, Jilani D, Funaki B. Effectiveness of collateral vein embolization for salvage of immature native arteriovenous fistulas. J Vasc Interv Radiol 2014;25:1890-4.  Back to cited text no. 10
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Janicki K, Pietura R, Bojarska-Szmygin A, Gieryng J, Orłowska A, Janicka L, et al. Chronic dialysis fistula thrombosis treatment by means of endovascular recanalization with surgical exclusion of developed collateral circulation. Ann Univ Mariae Curie Sklodowska Med 2003;58:219-21.  Back to cited text no. 12
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Sugimoto K, Higashino T, Kuwata Y, Imanaka K, Hirota S, Sugimura K, et al. Percutaneous transluminal angioplasty of malfunctioning Brescia-Cimino arteriovenous fistula: Analysis of factors adversely affecting long-term patency. Eur Radiol 2003;13:1615-9.  Back to cited text no. 20
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Ozkan B, Güngör D, Yıldırım UM, Harman A, Ozen O, Aytekin C, et al. Endovascular stent placement of juxtaanastomotic stenosis in native arteriovenous fistula after unsuccessful balloon angioplasty. Iran J Radiol 2013;10:133-9.  Back to cited text no. 23
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[PUBMED]  [Full text]  
Jennings WC, Miller GA, Coburn MZ, Howard CA, Lawless MA. Vascular access flow reduction for arteriovenous fistula salvage in symptomatic patients with central venous occlusion. J Vasc Access 2012;13:157-62.  Back to cited text no. 33


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2]


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