Balloon-assisted Maturation With Larger Diameter Balloons Should Be First-line Intervention for Nonmaturing Autologous Hemodialysis Access

Abstract

Serial balloon-assisted maturation (BAM) is a well-established method to develop functional arteriovenous fistulas (AVFs) but often require multiple reinterventions. We hypothesized that initial BAM with a larger diameter balloon will lead to earlier maturation of AVF and lower rates of reintervention. A retrospective review of 173 consecutive patients who underwent BAM between 2018 and 2020 by a single vascular surgeon at a hospital setting was performed. The cohort was divided into Group I: patients that underwent initial BAM with an 8-mm balloon (n = 121), and Group II: patients that had initial BAM with <8-mm balloon (n = 52). An 8-mm balloon was not used if contrast extravasation was observed after angioplasty with a smaller balloon. Only procedures performed to achieve initial AVF maturation were included, and procedures performed to maintain access patency were excluded. AVF was considered matured if successfully used for dialysis on 3 consecutive sessions. Demographic data, procedural details, and outcomes were compared between the two groups. A total of 222 BAMs were performed: 152 in Group I and 70 in Group II. The overall maturation rate was 99% (172/173). All demographics were similar, with the exception of more women in group II (61.5% vs 35.8%; P = .003). Based on preprocedure duplex, there was no difference in the vein size (4.4 ± 1.2 vs 3.9 ± 1.4 mm; P = .122) and volume flow (723 ± 450 vs 492 ± 370 mL/min; P = .079) between groups. However, higher rate of AVF stenosis was noted in Group II (39.5%) as compared with Group I (17.9%; P = .007). Seventy-nine percent (n = 94) of the AVFs in Group I achieved maturation after the initial BAM as compared with 54.9% (n = 28) in Group II (P = .001). Forty-four percent (n = 23) of patients in Group II required additional procedures to achieve maturation vs 22.3% (n = 27) patients in Group I (P = .001). There was a similar incidence of intraprocedural contrast extravasation and post-procedural hematoma in both groups (10.7% vs 17.3%; P = .23). None of the complications required intervention nor did it impact AVF patency. We demonstrated that utilizing large angioplasty balloons during initial BAM is safe and allows to achieve AVF maturation with fewer number of procedures.