Balloon Assisted Maturation With Large Balloons Should Be First-Line Intervention for Marginal Arteriovenous Fistulas

Abstract

Balloon assisted maturation (BAM) is a well-established method to develop functional arteriovenous fistulas (AVFs) but often requires multiple reinterventions. To achieve maturation, AVFs must be ∼6 mm in diameter. We hypothesized that larger diameter balloons (8 mm) would be needed to account for recoil during angioplasty and to achieve earlier maturation and a decreased number of interventions. We evaluated the outcomes of initial BAM with large diameter balloons. A retrospective review of 182 patients who had undergone BAM between 2018 and 2020 in an academic medical center was performed. The cohort was divided into two groups. Group I included patients who had undergone initial BAM with an 8-mm balloon (n = 128), and group II included patients who had undergone initial BAM with a <8-mm balloon (n = 54). An 8-mm balloon was not used if extravasation was observed after angioplasty with a smaller balloon. The AVF was considered matured if successfully used for dialysis on three consecutive sessions without further interventions. A total of 234 BAMs were performed: 150 in group I and 84 in group II. All demographics were similar between the two groups. The preprocedure duplex ultrasound showed no differences in the vein size (4.6 ± 1.1 mm vs 3.9 ± 1.2 mm; P = .705), volume flow (705 ± 426 mL/min vs 461 ± 354 mL/min; P = .631), or incidence of AVF stenosis (11.1% vs 1.6%; P = .189) between the two groups. The overall maturation rate was 95% (173 of 182) and was 98.4% in group I and 87% in group II (P = .001). Of the 150 AVFs in group I, 107 (83.5%) achieved maturation after the initial BAM compared with 23 of 84 AVFs (42.5%) in group II (P = .001). The incidence of intraprocedural contrast extravasation and postprocedural hematoma was similar between the two groups (11.7% vs 16.6%; P = .367). None of the complications required intervention nor did they affect AVF patency. The dialysis catheter dwell time was longer in group II than in group I (125 ± 56 days vs 112 ± 42 days; P = .034). The mean AVF diameter after BAM was 6 ± 1.4 mm in group I and 5.1 ± 1.5 mm in group II (P = .992). We conclude that BAM with large diameter balloons is safe and leads to higher AVF maturation rates and fewer reinterventions without an increased rate of complications. It also results in lower catheter dwell times, which might prevent long-term catheter complications. Our data support the theory that larger balloons are needed to achieve a 6-mm AVF diameter owing to vessel recoil after angioplasty.