Management of Arteriovenous Fistula Side Branches: Ligation or Coil Embolization

Abstract

Failure of maturation of arteriovenous fistulas (AVFs) remains an ongoing concern for dialysis access. One cause is the presence of side branches that divert flow from the main AVF channel. Both endovascular and surgical therapy can be used for eliminating side branches arising from the central conduit. The aim of this study was to evaluate the outcomes of endovascular and open surgical interventions for AVF side branches in the setting of maturation failure. A retrospective review of all patients during a 10-year period with primary radiocephalic and brachiocephalic AVFs was undertaken, and cases of maturation failure due to branch diversion were selected for study. Interventions were divided into endovascular (coil embolization) and surgical (branch ligation) interventions. Outcomes of maturation (successful progression to hemodialysis), reintervention, and functional dialysis (continuous hemodialysis for 3 consecutive months) were examined. From January 2008 to December 2018, there were 380 patients (65% female; age, mean ± standard deviation [SD], 57 ± 18 years) with poorly maturing radiocephalic (70%) and brachiocephalic (30%) AVFs who underwent intervention because of the presence of accessory venous branches. Indications were failure to mature in 54% and low flow in 46%. The average time to intervention due to failure to mature was 5 ± 4 weeks (mean ± SD) after primary access placement; 177 had coil embolization (ENDO) and 203 had open branch ligation (OPEN). Technical success was 90% in ENDO and 100% in OPEN. Technical ENDO failures had a secondary open ligation but were considered failures for the purposes of analysis; 54% and 48% of the AVFs in the ENDO and OPEN groups, respectively, had a concomitant downstream stenosis that required intervention by balloon angioplasty in 90% and patch angioplasty in the remainder. Repeated intervention by balloon-assisted maturation was required in 45% of all the cases, with no difference between ENDO and OPEN. Recannulation of the ENDO branches occurred in 10% of the cases, requiring repeated intervention; 71% of ENDO and 84% of OPEN matured to successful cannulation. Time to a matured access was 12 ± 4 weeks (mean ± SD) and 12 ± 4 weeks for ENDO and OPEN, respectively. Functional dialysis durations were equivalent between ENDO and OPEN groups. Endovascular and open surgical interventions for AVF side branches are successful, with OPEN having superior immediate outcomes but equivalent long-term outcomes.