Salvage of poorly developed arteriovenous fistulae with percutaneous ligation of accessory veins

Many arteriovenous (AV) fistulae fail to achieve an adequate blood flow or size for successful cannulation because of accessory veins. We describe a simple technique to ligate accessory veins that does not require a surgical incision. In this retrospective study, 17 end-stage renal disease patients underwent ligation of accessory veins of poorly developed AV fistulae. There were 14 men and 3 women, and their average age was 50 +/- 13 years. There were 14 radiocephalic and 3 brachiocephalic fistulae. After identifying accessory veins with a fistulogram, two nonabsorbable 2-0 polypropylene (Prolene) sutures were placed percutaneously around each accessory vein in proximity to the AV fistula. Successful ligation was confirmed with a repeat fistulogram. This procedure was undertaken after 4 +/- 3 months following surgical placement. Successful maturation was defined as adequate blood flow to support effective hemodialysis and adequate caliber to allow for repeated cannulation with a 15G or 16G needle. Of 17 AV fistulae, 15 (88%) successfully matured 1.7 +/- 1 month (range, 0.3 to 6 months) after the procedure. The average number of accessory veins ligated was 1.7 +/- 0.8 (range, 1 to 3). All AV fistulae that matured after ligation of accessory veins were functioning at 44.5 +/- 12 weeks after first use. A technique for salvaging nonmaturing AV fistulae not requiring surgical cutdown for ligation of accessory veins is described. AV fistulae mature quickly after ligation of accessory veins. This is a rapid and safe procedure that can increase the prevalence of AV fistulae.