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Pro/Con Failure of AVF Maturation is Typically Due To…: Poor Patient Selection, Lack of Pre-Op Imaging (Physician's Error)

While the goal of increasing the incidence of AV fistula placement is laudable, it is important to create those that are likely to function well enough to support hemodialysis. Poor patient selection and anatomic abnormalities can lead to fistulas that are technically successful but don’t mature. The elderly and obese populations, as well as those with limited life expectancy, are among those who should be carefully scrutinized prior to placement of an AV fistula for dialysis. Patients who have had many previous hospitalizations and central venous access have poorer options than those not previously manipulated. Definition of the anatomy prior to the placement of an AV fistula allows for an increased incidence of placement of the fistula (1-3). While a detailed physical exam can frequently demonstrate adequate arterial and venous structures, routine application of venous mapping has been demonstrated to be successful in allowing increased creation of AV fistulas. Importantly, venous mapping can allow one to avoid veins deemed too small for success (4), as well as other quantifiable indices (5). Adequate patient selection combined with venous mapping can improve the placement of AV fistulas that mature to the point of adequately supporting hemodialysis. Successful AV fistula placement prior to the need for dialysis can benefit the ESRD patient. References 1. Allon M, Lockhart ME, Lilly RZ, et al. Effect of preoperative sonographic mapping on vascular access outcomes in hemodialysis patients. Kidney Int 2001; 60: 2013-20. 2. Gibson KD, Caps MT, Kohler TR, et al. Assessment of a policy to reduce placement of prosthetic hemodialysis access. Kidney Int 2001; 59: 2335-45. 3. Robbin ML, Gallichio MH, Deierhoi MH, Young CJ, Weber TM, Allon M. US vascular mapping before hemodialysis access placement. Radiology 2000; 217: 83-8. 4. Silva MB Jr, Hobson RW, Pappas PJ, et al. A strategy for increasing use of autogenous hemodialysis access procedures: Impact of preoperative noninvasive evaluation. J Vasc Surg 1998; 27: 302-7; discussion 307-8. 5. Malovrh M. Native arteriovenous fistula: Preoperative evalauation. Am J Kidney Dis 2002; 39: 1218-25.