Salvage of Hemodialysis AV Fistulae after Complications of Balloon Maturation

Objectives: Autogenous arteriovenous (AV) fistula remains the optimal access for patients undergoing hemodialysis for treatment of end stage renal disease. Current utilization of small veins for AV fistulae results in a significant incidence of poor access maturation. Recent efforts to improve fistula maturation with balloon angioplasty has resulted in significant improvement in utilization of autogenous fistulas which might previously have been abandoned. Unfortunately, balloon maturation may result in complications which threaten the integrity of the access and require surgical intervention.
Methods: Over a 4 year period, 971 patients had balloon maturation of autogenous AV fistulae. Eight patients had disruption of the AV fistula anastomosis or outflow vein resulting in formation of a pseudoaneurysm. Repair of five anastomotic disruptions involved reanastomosis of the outflow vein to the artery proximal to the previous fistula site. Two outflow venous disruptions were repaired with endovascular placement of a covered stent or interposition grafting. One outflow vein was extensively disrupted and not amenable to repair.
Results: Five anastomotic pseudoaneurysms were successfully repaired with continued patency and successful hemodialysis access. One outflow vein was extensively disrupted and not amenable to salvage. A fistula was successfully performed at a more proximal level in the same extremity. Two additional venous disruptions were successfully repaired with covered stent placement or interposition grafting.
Conclusions: The complication rate of balloon maturation is remarkably low and includes disruption of the AV fistula anastomosis and outflow vein. These complications can be successfully managed, preserving fistula patency for future access. By combining surgical techniques for fistula placement and endovascular techniques for fistula maturation autogenous access can be achieved in significantly more patients than was previously feasible.