A Single-Center Before-and-After Study of Physiology-First Algorithmic Surveillance Versus Standard Observation for Arteriovenous Fistula Maturation

Objective To evaluate whether a structured, physiology-first surveillance protocol improves arteriovenous fistula (AVF) clinical maturation rates and reduces time to cannulation readiness compared with standard postoperative observation. Methods Two consecutive cohorts of surgically created AVFs by a single surgeon at a community-based center were compared: a standard observation cohort (January–May 2025; 64 created, 58 analyzable), and a physiology-first cohort (June 2025–March 2026; 52 created, all analyzable) managed with a structured protocol featuring standardized 2.7-mm anastomosis, day-of-creation (DOC) baseline flow documentation, structured ultrasound surveillance at weeks 2 and 4, and defined failure-to-progress intervention triggers and procedure. Salvage intervention for both cohorts included kinetic endovascular microincision creation followed by angioplasty with a drug-coated balloon. Results Overall maturation increased from 75.9%(44/58) to 92.3% (48/52; P=0.022). Unassisted maturation rose from 53.4%(31/58) to 69.2% (36/52). The overall median time to clinical maturation decreased from 49 days (IQR 42–68) to 30 days (IQR 26–43; P <0.001). Salvage intervention success was comparable between cohorts. DOC flow documentation increased from 0% to 100% and no steal syndrome was observed (0/52) with the new physiology-first protocol. Conclusions As a quality-improvement evaluation, the physiology-first protocol generated a clear and consistent signal of improved maturation outcomes: access failure decreased, unassisted maturation increased, overall maturation increased and median time to cannulation readiness decreased. These findings support adopting the protocol as a meaningful adjunct to care and warrant multi-center evaluation.