The Impact of Reintervention on Arteriovenous Fistula Maturation and Functional Patency in the Hemodialysis Fistula Maturation Study

Rationale & Objective Arteriovenous dialysis fistula(AVF) reinterventions are sought to assist with maturation and/or maintain functional patency; however, their ultimate impact on fistula lifespan remains poorly documented. Furthermore, current clinical practice guidelines lack clarity regarding reintervention paradigms to achieve optimal AVF performance. Therefore, the purpose of this study was to document reintervention rates and their association with AVF maturation and functional patency among patients enrolled in the Hemodialysis Fistula Maturation (HFM) study. Study Design Retrospective review of a prospective observational cohort study. Setting & Participants 535 HFM study patients that underwent maturation adjudication across 7 academic centers. Exposures Pre- and post-maturation reinterventions (i.e., revisional procedures) for single-stage, upper extremity AVFs. Outcomes AVF reintervention-associated maturation success and functional patency. Analytical Approach Descriptive statistical methods, including Kaplan-Meier methodology, characterized unadjusted reintervention outcomes. Results 396(74%) AVFs were successfully used for dialysis. 37%(N=196/535) underwent 274 reinterventions(181-endovascular, 93-open) to facilitate maturation. Factors associated with pre-maturation reintervention included female sex, diabetes, peripheral vascular disease, and elevated BMI. Following maturation, 47%(N=188/396) of the patients with a functional AVF underwent 477 reinterventions. The post-maturation reintervention clinical success rate was 70%(endovascular-72%[N=312/435];open-55%[N=23/42]). Assisted maturation AVFs demonstrated inferior functional primary patency (p=0.002) but equivalent cumulative functional patency(p>.9) compared to unassisted maturation fistulas. Post-maturation abandonment rate was 24%(N=95/395). Limitations AVF management decisions were made by the individual surgeons, so this study cannot account for physician and center selection bias related to access use, remediation or abandonment. Furthermore, AVFs were exclusively managed at academic institutions, so results may not be generalizable across all healthcare settings. Finally, prosthetic conduits were not evaluated. Conclusions AVF reinterventions are common and are not associated with inferior maturation or functional patency rates. Timely remediation should be considered when clinically indicated, although AVFs remain at high-risk for subsequent reinterventions, with durable outcomes requiring meticulous surveillance.