An investigation of the Effect of Antihypertensive drugs on Arteriovenous Fistula Maturation in Patients with Hemodialysis

Background and aimsArteriovenous fistula (AVF) maturation failure rates remain high in patients with end-stage renal disease (ESRD). Although preoperative morphological and functional assessment of blood vessels by duplex ultrasonography (DUS) has been shown to improve AVF maturation, there is no consensus regarding the optimal vein (VD) and artery (AD) diameters to be universally used for AVF creation. To improve patient selection, set out to investigate if there is a correlation between preoperative VD/AD and clinical covariates, and postoperative AVF outcome.MethodsThis was a prospective cohort study conducted during January–August 2014. ESRD patients referred to “Niculae Stăncioiu” Heart Institute Cluj-Napoca, who had a VD ≥1.9 mm and AD ≥1.5 mm, as measured by DUS, and underwent AVF creation were enrolled. We assessed whether preoperative VD/AD and clinical covariates were associated with AVF maturation rate and primary patency at 2 years after AVF creation.ResultsOf 115 patients referred for AVF creation, 93 were included in the study. Mean (± standard deviation) VD was 3.3 ± 1.1 mm and VDs were distributed in quartile Q1 <2.55 mm, Q2: 2.56–3.10 mm, Q3: 3.11–3.70 mm and Q4: >3.71 mm. Mean AD was 3.3 ± 1.4 mm and ADs were distributed in Q1 <2.55 mm, Q2: 2.56–3.10 mm, Q3: 3.11–3.70 mm, and Q4, >3.71 mm. AVF maturation rate increased proportionally with VD from Q1 (62%) to Q2 (70%), Q3 (82%) to Q4 (96%) (p=0.03). Based on AD, a higher AVF maturation rate was observed in Q3 (86%), Q4 (83%) vs Q1 (71%) and Q2 (67%). Long-term primary patency of AVFs seemed not to be influenced by VD and AD. In older patients and those with peripheral arterial disease, AVF maturation failure tended to be higher.ConclusionsOur findings suggest that a preoperative VD ≥1.9 mm and AD ≥1.5 mm have a successful maturation rate of AVF greater than 60% in ESRD patients. The maturation rate of surgical AVF increases proportionally with the size of VD used for AVF creation.

Arteriovenous fistula maturation rate is not affected by ipsilateral tunneled dialysis catheter

Preoperative color Doppler ultrasound parameters for surgical decision-making in upper arm arteriovenous fistula maturation

Changing vascular integrity with aging may be a crucial factor presuming Arterio-Venous fistula (AVF) maturation. Present study compared outcome of AVF maturation and associated factors responsible between adult and elderly population. In this prospective observational study, CKD 4/5 patients of age ⩾18 years in whom AVF was planned were included. All were divided as adult (18-59 years) and elderly (⩾60 years) groups. Various clinical, biochemical, and radiological parameters including doppler assisted vascular mapping were recorded. AVF was created by side to side anastomosis. Clinical and doppler assessment like blood flow and wall shear stress (WSS) were done at 4th, 6th, and 12th weeks. Radiological maturation of AVF was defined as combination of blood flow of ⩾500 mL/min and vessel diameter of 5 mm. At 12 weeks, maturation of both group and association of biochemical factors with primary AVF failure were compared. A total of 120 patients (60 in each age group) were included. Overall AVF maturation rate was 75% (n = 90). Among elderly 70% (n = 42) and adult 80% (n = 48); p < 0.02. Early clinical and radiological maturation were seen in adult as compared to elderly (p = 0.022). Hyperphosphatemia, and higher c-reactive protein (CRP) levels were associated with AVF primary failure (p = 0.033) and (p = 0.005) respectively which are more in elderly group. Elderly patients had more arterial calcification (p = 0.034). Radio cephalic AVF (RCAVF) was common in both group, adult (85%) and elderly (76.5%), however elderly have more brachiocephalic AVF (BCAVF) (14.8% vs 23.3%). Blood flow, fistula diameter, and WSS had significant differences between the matured and non-matured groups (p < 0.001) in both adult and elderly. Higher serum phosphate level, CRP, arterial calcification, and higher WSS were likely cause of reduced AVF maturation rate in elderly. Meticulous clinical, biochemical, and radiological evaluation, site of AVF creation selection are essential to reduce AVF failure rate.

Fistula Salvage by Endovascular Therapy

It is necessary to assess the association between the preoperative indicators and the maturation and survival of arteriovenous fistula (AVF). We retrospectively identified 236 patients with a new AVF created between 2016 and 2018 in our Dialysis Center. Multivariate Logistic regression showed that preoperative arterial diameter (odds ratio [OR] = 1.452, 95% confidence interval [CI] [1.233, 1.710], p < 0.001), preoperative venous diameter (OR = 1.296, 95% CI [1.166, 1.477], p < 0.001), left ventricular ejection fraction (LVEF) (OR = 1.187, 95% CI [1.103, 1.277], p < 0.001), and diabetes mellitus (OR = 0.245, 95% CI [0.107, 0.560], p = 0.01) were independent influential factors for AVF maturation. Two years after the AVF surgery follow-up, multivariate Cox proportional-hazards model showed that the preoperative arterial diameter (OR = 0.510, 95% CI [0.320, 0.813], p = 0.005), preoperative venous diameter (OR = 0.940, 95% CI [0.897, 0.985], p = 0.010) and diabetes mellitus (OR = 1.785, 95% CI [1.117, 2.855], p = 0.016) was prognostic factors of AVF survival. The Kaplan-Meier method showed that the primary survival of AVF in patients with different preoperative arterial diameter was statistically significant (log-rank χ2 = 15.415, p < 0.001), while the secondary survival was not statistically significant (log-rank χ2 = 0.131, p = 0.717). In our cohort, the preoperative arterial and venous diameter and diabetes mellitus were independent influential factors for AVF maturation and prognostic factors of AVF survival. However, the preoperative LVEF only associated with the maturation of AVF. Meanwhile, smaller arterial diameter (≤2.15 mm) was associated with AVF maturation failure, but did not impact secondary survival of AVF.

Gelsolin is a key regulator of actin filament metabolism and plays a role in tissue remodeling. We evaluated plasma gelsolin (pGSN) in predicting arteriovenous fistula (AVF) maturation. Only patients with newly created radiocephalic AVF were included. pGSN and plasma F-actin levels were measured preoperatively. Maturation was defined as an access (cephalic) vein diameter > 5mm and a fistula blood flow rate > 500mL/min in ultrasound, 8weeks after operation. A total of 68 patients were analyzed with a mean age of 62.6 ± 11.1years. AVF maturation was identified in 39 patients (57.3%). Mean pGSN level was 4726 (3836-6483) ng/mL in patients with mature AVF and 3237 (2895-4382) ng/mL in patients with immature AVF. pGSN levels were significantly higher (p < 0.001) in the mature AVF group. F-actin levels were not significantly different between two groups. pGSN levels positively correlated with fistula blood flows (r = 0.326, p = 0.007). Multivariate logistic regression analysis revealed that pGSN (p = 0.003) was determined to be an independent risk factor in predicting AVF maturation. Preoperative pGSN levels were significantly predictive of AVF maturation in the ROC analysis. Sensitivity and specificity of pGSN were 82.1% and 58.6%, respectively, with a cut-off value of > 3716ng/mL and an area under the ROC curve of 0.75 (95% CI: 0.64-0.87, p < 0.001). Current results demonstrated that patients with mature AVFs had significantly higher preoperative pGSN levels compared to those with immature AVFs. Outcomes suggest that pGSN could serve as a predictive biomarker for AVF maturation.

The progression of atherosclerosis in small and medium-sized vessels has been associated with Type 2 diabetes (T2D). However, the influence of T2D on postoperative vascular remodeling and arteriovenous fistula (AVF) maturation is inconclusive. Besides, hemodynamic changes of postoperative vessel are also associated with AVF maturation. This study is intended to investigate the link between T2D and the occurrence of AVF non-maturation, as well as to delve into the impact of postoperative vascular hemodynamic parameters in this process. A total of 477 hemodialysis patients, with or without type 2 diabetes, underwent AVF creation at Beijing Haidian Hospital (Haidian Section of Pecking University Third Hospital) from August 2018 to March 2022 were collected, and were followed for 1-5years. Logistic regression was applied to analyze the association of T2D, postoperative vascular hemodynamic parameters with the risk of AVF non-maturation. To verify the stability of the results, the sensitivity analyses were performed using propensity scores to match patients. We further investigated the regulatory role of the postoperative vascular hemodynamics. There were 173 patients with T2D and 304 patients without T2D in this study. The maturation rate in T2D and non-T2D group was 47.977% and 63.816%, respectively. The findings of logistic regression analysis suggested that T2D significantly increased the risk of AVF immaturity [OR 1.716 (1.019-2.890), P = 0.042]. Besides, T2D was associated with the restriction of postoperative vascular hemodynamic parameters changes, including with decreased diameter of forearm cephalic radial artery and dilation rate of radial artery. The result of logistic regression analysis indicated that cephalic vein diameter at 1-month [0.402 (0.237-0.681), P = 0.001] and cephalic vein diameter at 2-month [0.501 (0.355-0.708), P < 0.001] were independently correlated with AVF maturation. Besides, the results of sensitivity analysis were consistent with that of logistic regression analysis. Moreover, the mediating effects of cephalic vein diameter were significant. Our findings discovered that T2D significantly increased the risk of arteriovenous fistula non-maturation, which was mainly mediated by the changes of cephalic vein diameter.

BACKGROUND AND AIMS In hemodialysis patients, assessment of arterio-venous fistula (AVF) maturation is key to reduce the residence time of central venous catheters (CVC). We have introduced the use of central-venous oxygen saturation (ScvO2) and estimated upper-body blood flow (eUBBF) as means to monitor AVF maturation [1]. We now report CVC residence time in patients with and without ScvO2-based AVF maturation monitoring. METHOD We studied hemodialysis patients in who ScvO2-based AVF maturation monitoring was implemented within the framework of a clinical quality improvement project (QIP). ScvO2 and hematocrit were measured with Crit-Line (Fresenius Medical Care, Waltham, MA). eUBBF was computed as described previously [1]. We used time-to-event analysis to compare the CVC residence time post-AVF creation between patients who participated in the QIP (intervention group) and non-QIP patients (control group). Both groups were dialyzed in the same geography. Patients were censored at the time of death, change of dialytic modality, transplantation, lost to follow up, recovery of kidney function and end of the observation period (15 November 2021). RESULTS The intervention group comprised 44 patients [age 57 ± 17 years; 27 (61%) males]. In five patients, two AVF were created; in 34 (69%) CVC were removed. The control group comprised of 378 patients (age 59 ± 15 years, 61% males). CVC was removed in 199 (53%) control patients. In the intervention group, CVC were removed 125 days [95% confidence interval (95% CI): 102–171] after AVF creation. In the control group, this time was 236 days (95% CI: 173–404) (P &amp;lt; 0.0003; log rank test; Figure). CONCLUSION Compared to controls, the CVC residence time post AVF-creation was shortened significantly— by about 3.6 months—in patients who participated in a QIP that used ScvO2-baseed assessment of AVF maturation. Measurement of ScvO2 and computation of eUBBF are simple, non-invasive means to track AVF maturation, trigger timely interventions and AVF cannulation and shorten CVC residence time.

This study aimed to determine the risk factors associated with the failure of arteriovenous fistulae (AVF) maturation. This retrospective cohort study was conducted from January 2014 to December 2018 in Sultan Qaboos University Hospital, Muscat, Oman. Patients were followed-up 3 months after surgery, and their electronic medical records were accessed for demographic and clinical data. Univariate analysis was used to determine the risk factors associated with early AVF maturation and multivariant analysis was used to determine the predictive factors for AVF failure. A total of 269 patients were included. Female gender was a significant factor affecting AVF maturity (P = 0.049), while age (P = 0.626), diabetes (P = 0.954), hypertension (P = 0.378), dyslipidaemia (P = 0.907), coronary artery disease (P = 0.576), cerebrovascular accident (P = 0.864), congestive heart failure (P = 0.685), previous central venous catheterisation (P = 0.05), fistula type (P = 0.863) and fistula site (P = 0.861) did not affect AVF maturation. Binary logistic regression showed that all the risk factors were insignificant. Failure of early AVF maturation affected 11.5% in the cohort. This study found that the proportion of early AVF maturation at our hospital is at par with that in the international literature. Failure of AVF maturation was significantly associated with the female gender. These findings can help nephrologists and vascular surgeons prognosticate AVF maturation rates. However, a larger study is needed for definitive conclusions.

the external support device VasQ is intended to promote arteriovenous fistula (AVF) maturation by maintaining the optimal anastomotic angle in order to minimize blood flow disturbances around the anastomotic area. The aim of the study is to assess efficacy and safety of the VasQ device both in brachiocephalic and radiocephalic fistulae. a single institution prospective study was conducted with implantation of the VasQ device during AVF creation. Clinical and Doppler ultrasounds evaluations were performed at day-1, 1, 6, and 12 months for assessment of device-related adverse events, AVF maturation and patency. Moreover, volume flow rate and diameter of outflow vein were measured. A total of 16 patients were enrolled. Ten brachiocephalic and 6 radiocephalic AVFs were created with VasQ. Preoperatively cephalic vein diameter was 3.6 ± 0.9 mm. our population included 13 male and 3 females patients, 9 end stage kidney disease in conservative therapy, 4 dialysis treated patients, and 3 transplanted patients; mean age was 74.0 ± 8.1 years; no severe device-related adverse events were observed. Primary patency at 1, 6, and 12 months was 100%, 87.5%, and 67.7%, respectively, while secondary patency was 100%, 100%, and 78.3%, respectively. Comparing brachiocephalic to radiocephalic AVFs no significant differences in patency rates were seen. Overall maturation rate was 94% (15/16). Mean vein diameter measured with Doppler ultrasound at postoperative day-1 and at 1, 6, and 12 months was 5.0 ± 1.0, 5.9 ± 0.9, 7.2 ± 1.6, and 7.9 ± 1.4 mm, respectively, with a mean flow rate at the brachial artery of 841 ± 176, 1052 ± 224, 1261 ± 490, and 1348 ± 477 ml/min, respectively. in our limited experience VasQ was safe, with high maturation and patency rates. Positive results suggest a potential benefit for VasQ in AVF.

Introduction: Patients on haemodialysis require either an intravenous cannula or an arterio-venous (AV) fistula for haemodialysis. Multiple factors are involved in the maturation of an AV fistula and this retrospective study was designed to look into the relationship of atorvastatin usage affecting AV fistula maturation. Methods: A retrospective cohort of 89 patients who underwent arterio-venous fistula creation from the year 2023 - 2024 in Hospital Sultan Haji Ahmad Shah (HoSHAS), Temerloh were analysed in this study. Patients were divided into 2 groups: (1) patients that were on regular atorvastatin, (2) patients not on atorvastatin. Results: A total of 89 patients underwent AV fistula creation. Patients in group 1 had an overall success rate of 53% with 3 failures. Meanwhile, the patients in group 2 had a success rate of 46% with 7 failures. Discussion: Significant statistical difference observed in outcome of AV fistula maturation in the group of patients that received atorvastatin. (p value 0.011). However, a number of confounding factors such as the dose of atorvastatin, surgeon factor, ages of the patients, dose of atorvastatin and patients with chronic kidney disease (CKD) or End Stage Renal Failure (ESRF) could affect the outcome of this study. Conclusion: Results of this study showing positive relationship of atorvastatin usage with Brachiocephalic fistula (BCF) maturation.

Early identification of autogenous arteriovenous fistula (AVF) maturation failure in patients with end-stage renal disease (ESRD) is crucial, as it enables early interventions that can enhance AVF maturation rates and reduce the duration of catheter use. This study aimed to identify factors that may predict arteriovenous fistula maturation in patients undergoing maintenance hemodialysis. This retrospective study included a cohort of 532 ESRD patients who underwent AVF creation and routine follow-up at the Beijing Haidian Hospital (Haidian Section of Pecking University Third Hospital) from August 2018 to March 2022. A total of 532 patients were randomly divided into a training cohort (389 cases) and a validation cohort (143 cases). Patients in each cohort were categorized into mature and non-mature groups based on whether they met clinical or ultrasound criteria 3 months after AVF creation. The timing of early intervention for non-maturation AVF was preliminarily discussed after a risk prediction nomogram for non-maturation in newly AVF creation was constructed. Of the 532 patients, 379 (73.24%) achieved fistula maturation at 3 months postoperatively. We randomly divided the total study population using computer-generated randomization into a training cohort (n = 389) and a validation cohort (n = 143) in an approximately 7:3 ratio. Analysis of the training cohort revealed that the anastomotic diameter (anas1), the internal diameter of the anastomotic vein (V1), brachial artery blood flow (F1) at 1 month, and brachial artery blood flow (F3) at 3 months postoperatively were associated with AVF maturation. A maturation nomogram was developed for the training cohort, yielding an area under the curve (AUC) of 0.938 (95% confidence interval [CI], 0.908-0.967), with a sensitivity of 0.911 and a specificity of 0.856. The model was validated in the validation cohort, showing an AUC of 0.927 (95% CI, 0.879-0.975), with a sensitivity of 0.870 and specificity of 0.886. The calibration curve showed strong agreement between nomogram predictions and actual observations. The anastomotic diameter (anas1), the internal diameter of the anastomotic vein (V1), brachial artery blood flow (F1) at 1 month, and brachial artery blood flow (F3) at 3 months postoperatively can predict the unassisted maturation of AVF.

Hemodialysis vascular access is the “lifeline” for patients on hemodialysis. Unfortunately, because of its poor patency and significant complication rate, it is also the “Achilles heel” of hemodialysis. For example, the current unassisted arteriovenous fistula (AVF) maturation rate is only

Failure of arteriovenous fistula (AVF) maturation is attributed to impaired vein remodeling. The purpose of this study is to identify whether vein matrix metalloproteinase (MMP) expression and activity is associated with AVF maturation. Patients with renal insufficiency undergoing surgery had their vein segments harvested and snap-frozen at time of AVF construction. Expression of MMP-2, MMP-9, membrane type-1 MMP (MT1-MMP), tissue inhibitor of metallopreoteinases type 2 (TIMP-2), and TIMP-4 were measured using zymography and Western blotting techniques. Of 14 patients enrolled, 9 had successful maturation and 5 had failure of AVF maturation. Significantly higher levels of MT1-MMP (an MMP-2 activator; P = .01), TIMP-2 (an MMP-2 inhibitor; P = .03), MMP-2 latent (P = .02), and MMP-2 total (P = .03) were associated with AVF maturation. There was a trend toward higher levels of TIMP-4 in the successful group (P = .18). These data demonstrate a positive relationship between MMP-2 expression in veins and AVF maturation. MMP-2 could serve as a potential preoperative marker to predict maturation.