Initial Experience and Lessons Learned with Percutaneous Creation of Arteriovenous Fistulae for Dialysis Access

Abstract

In the United States, 800,000 people are currently being treated for end-stage kidney disease with 1600 per million on hemodialysis. Upcoming National Kidney Foundation guidelines endorse a "Patient Life-plan, Access Needs" approach, and new technologies are introducing percutaneous creation of arteriovenous fistulae for this population. Here, we describe our initial experience with percutaneous arteriovenous fistula (pAVF) creation. We reviewed prospectively collected data on our first 43 patients undergoing percutaneous creation of AVF using the Ellipsys Vascular Access System (Avenu Medical Inc, San Juan Capistrano, Calif). The procedure is an outpatient, single venous access, ultrasound guided creation of a pAVF between a deep perforating vein and the proximal radial artery. We examined the early global functional outcomes of pAVF creation. All cases were performed in an outpatient procedure center. Technical success was 88.3%. There were seven early occlusions requiring standard surgical AVF creation. Twenty-one required early fistulagrams/maturation procedures. Of these, eight have required more than one procedure. Intervention was performed most commonly from a radial arterial access. Five patients have required superficialization procedures (4 basilic, 1 cephalic). Two patients required basilic vein ligation. Eleven patients have clinically mature AVF but are not yet on dialysis. Fifteen patients are currently dialyzing. Overall primary-assisted patency is 79.1% for the entire cohort. The technical learning curve for pAVF creation is short, especially for those with endovascular experience and comfort with ultrasound-guided procedures. Where the learning curve exists is in the interpretation of the low-flow hemodynamics in these fistulas; when and where to access the mature pAVF; and how to effectively communicate strategy with dialysis centers. Early interrogation and intervention seem common in order to establish the fistula, but durability appears achievable with a coordinated effort.