Arteriovenous Fistula Failure Research Articles (Page 1)

Arteriovenous fistula (AVF) failure is a frequent clinical problem among end stage renal patients seeking durable long term dialysis access. The most common histological in vivo observation of AVF failure is endothelial injury at the juxta-anastomosis area (JAA) followed by thrombus deposition and subsequent neointimal hyperplasia (NH). While hemodynamic factors have been postulated to affect AVF remodeling and failure, the spatial correlations between changes in hemodynamics post AVF creation and in vivo physiologic observations remain poorly understood. In this work, we developed a novel computational fluid dynamics (CFD) model of an AVF using a pre-established aortocaval mouse model and integrated it with agent-based modeling for NH. The CFD simulation was performed using an animal-specific aortocaval fistula geometry derived from in vivo CTA images with prescribed boundary conditions obtained from in vivo ultrasound measurements. CFD results were validated against in vivo ultrasound velocity measurements at the level of the fistula. CFD allowed quantification of turbulence intensities throughout the fluid domain of the AVF. Turbulence was significantly elevated at the JAA and in regions of venous outflow stenosis. Turbulence intensity served as an input parameter for a simple two-rule agent-based model to test the hypothesis that non-homeostatic hemodynamic changes resulting from AVF creation drive spatial gradients in endothelial damage and proliferation of vascular smooth muscle cells (VSMC) leading to an increase in venous thickness or NH. Our findings show that increased velocity and turbulence in the JAA parallels in vivo NH formation, and that further from the JAA (both cranial and caudal) velocity and turbulence decrease incrementally. The results corroborate that perturbed hemodynamics in the JAA are potential triggers for NH and the source of thickness gradients observed in AVFs.

Background: The optimal vascular access for hemodialysis is an arteriovenous fistula (AVF), yet the failure rates range from 30% to 40%. Accessory veins modify blood flow, contributing to 40% of early failures. The treatment for stenosis is clearly established, whereas accessory vein treatment is not. Case Illustration: Two cases of endovascular coil embolization for accessory vein obliteration were performed at Saiful Anwar Hospital, Malang. The first case involved a 47-year-old female with late arteriovenous fistula failure, which was fixed with a percutaneous transluminal angioplasty and coil embolization. The second case involved a 58-year-old male with early radiocephalic arteriovenous fistula failure, which was also treated with a percutaneous transluminal angioplasty and coil embolization. Both procedures achieved complete elimination of the accessory vein and showed no signs of retrograde flow. The first and second cases have different onsets of early and late failure. Both patients required PTA and coil embolization simultaneously. Conclusions: Endovascular coil embolization is a safe and effective technique for occluding accessory veins in AVF, which helps improve their function in both early and late failures and shows higher success rates. Keyword : Accessory veins; Arteriovenous fistula; Coil embolization.

Background Arteriovenous fistulas (AVFs) are the preferred vascular access for hemodialysis (HD); however, primary failure remains a significant concern. Postoperative exercise is often recommended. Emerging evidence suggests potential benefits of preoperative exercise in improving AVF outcomes. This study aimed to evaluate the impact of a preoperative upper limb exercise regimen on vessel diameters and AVF maturation rates in patients scheduled for radiocephalic AVF creation at a tertiary care center in India. Materials and Methods Thirty patients with ESKD scheduled for radiocephalic AVF creation were prospectively recruited from the Department of Urology, AIIMS Patna. The participants undertook a supervised 6-week self-directed daily upper-limb exercise program. The baseline and post-exercise cephalic vein and radial artery diameters were measured using duplex ultrasonography. Handgrip strength was also assessed. Patients were followed up for 6 months postoperatively to assess the primary AVF failure rates. Results Mean hand grip strength significantly improved from 19.8±5.9 kg to 21.5±6.2 kg (p=0.008) after the exercise. Cephalic vein diameter did not change significantly in all patients (from 2.15±0.65 mm to 2.28±0.70 mm, p=0.09). However, in patients with high adherence (≥ 34 days of exercise, n=18), a statistically significant increase in the mean cephalic vein diameter at the wrist was noted (from 2.18±0.60 mm to 2.40±0.68 mm, p=0.02). The primary AVF failure rate at 6 months was 23.3% (7/30 patients). Conclusion Preoperative upper limb exercise therapy demonstrated a positive trend of increasing venous diameter, particularly in adherent patients, and was associated with improved handgrip strength. These findings suggest a potential role of preoperative exercise in optimizing the conditions for AVF creation.

Background: Arteriovenous fistulas are the preferred vascular access for hemodialysis. However, their failure remains a significant challenge. Several factors contribute to their failure including vascular calcifications, which is one among them. The present study aimed to analyse the role of Abdominal aortic calcification and Vascular access calcification in predicting poor fistula maturation and patency. Methods: This was a prospective observational study of 200 patients with CKD (stages 4 and 5) who underwent fistula surgery between August 2022 and August 2023, with preoperative radiological assessment by lateral abdominal radiography for Abdominal aortic calcification, upper limb radiography for Vascular access calcification, and upper limb Doppler for vessels, and 146 patients were followed up for 1 year. The association between vascular calcification and fistula failure was analysed. Results: Abdominal aortic and Vascular access calcifications were observed in 29% and 19% of the study population, respectively. The observed primary failure rate (within 3 months) was 24.5% and the secondary failure rate (at 1 year) was 15.7%. High-grade calcification of the abdominal aorta and vascular access were associated with significantly higher fistula failure rates, with primary failure rates of 84.6% and 54.1%, and secondary failure rates of nearly 100% and 66.6%, respectively. Logistic regression analysis revealed that Abdominal aortic calcification and Vascular access calcification independently predicted primary and secondary fistula failures. Conclusion: Abdominal aortic calcification and Vascular access calcification are associated with poor maturation and increased failure rates of Arteriovenous fistulas. This emphasizes the significance of proper preoperative assessment of vessels, which helps in patient selection for fistula and thus potentially improves outcomes.

Abstract Background and Aims Arteriovenous fistula (AFV) failure remains a significant challenge in patients with hemodialysis. Vascular calcification plays a critical role in AVF dysfunction. Fetuin-A, a glycoprotein synthesized in the liver, is a systemic inhibitor of vascular calcification. While low fetuin-A levels have been linked to increased vascular calcification, there has been no meta-analysis concluding the relationship between fetuin-A serum levels, arterial calcification, and AVF failure. This study aims to evaluate the relationship between fetuin-A levels and AVF failure through vascular calcification in CKD patients undergoing hemodialysis. Method This is a systematic review and meta-analysis conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guideline (Fig. 1). This study has been registered at PROSPERO (CRD42025634399). A literature search was conducted in PubMed and ScienceDirect on October 1st 2024. Data were analyzed using Review Manager for calculating pooled hazard ratio and standardized mean difference (SMD), while MedCalc software was used to calculate the pooled correlation coefficient. Results A total of 26 observational studies were included. Meta-analysis showed that fetuin-A levels were negatively correlated with vascular calcification (r = −.530; 95% CI [−0.781 to −0.132]; P = 0.011). The mean fetuin-A levels were lower in the group with vascular calcification than those without calcification (SMD = −1.71; 95% CI [−2.58 to −0.85]; P = 0.0001). Patients with vascular calcification had a 2.98 times higher risk of AVF failure (OR = 2.98; 95% CI: 1.78–4.99; P < 0.0001). Three studies showed that high fetuin-A levels were a protective factor against AVF failure (HR = 0.76; 95% CI [0.63–0.91]; P = 0.003). Conclusion Low fetuin-A levels were associated with increased vascular calcification and a higher risk of AVF failure in CKD patients undergoing hemodialysis. These findings suggest the potential mechanism of fetuin-A as a predictive biomarker and therapeutic target in reducing AVF failure. Further studies with standardized testing methods are recommended to confirm this association.

Owing to insufficient understanding of the molecular basis of arteriovenous fistula (AVF) failure, strategies to facilitate maturation and prevent access loss remain limited. This study aimed to identify potential biomarkers for AVF nonmaturation. We enrolled 123 patients with end-stage renal disease who underwent AVF surgery. Finally, 86 were classified into AVF matured (AM; n = 52) and AVF nonmatured (ANM; n = 34) groups following exclusion. Four cephalic vein tissue samples from each group were used for data-independent acquisition-mass spectrometry (DIA-MS) proteomic analysis to identify differently expressed genes. All 86 vein tissue samples were used for histological analysis, and all serum samples were used for ELISA. DIA-MS proteomic analysis identified 17 upregulated and 363 downregulated proteins in the ANM group compared with the AM group. Fibrinogen α (FGA), fibrinogen β (FGB), and fibrinogen γ (FGG) were the most activated proteins. Univariate logistic regression analysis revealed collagen volume fraction (CVF) (odds ratio [OR] = 1.278, 95% confidence interval [CI] 1.133-1.440, P < 0.001), FGA (OR = 1.005, 95% CI 1.003-1.007, P < 0.001), FGB (OR = 1.269, 95% CI 1.147-1.403, P < 0.001), and FGG (OR = 1.010, 95% CI 1.007-1.014, P < 0.001) as potential independent predictors of AVF nonmaturation. Multivariable logistic regression models further confirmed that FGA, FGB, and FGG could predict AVF outcomes. This study suggested high FGA, FGB, and FGG levels are risk factors for AVF nonmaturation and could be potential biomarkers.

Hemodialysis is the most prevalent modality of renal replacement therapy. The durability of hemodialysis and its quality depend on consistent and reliable access to the patient's vascular system. In this systematic review we provide a comprehensive analysis of the predictors of primary arteriovenous fistula failure. A systematic search was conducted in PubMed, Web of Science, ScienceDirect, and the WHO Virtual Health Library Regional Portal from database inception through March 2025. Search terms included combinations of 'arteriovenous fistula', 'failure', 'hemodialysis', 'end-stage renal disease', and 'risk factors'. Four reviewers independently screened titles and abstracts, with full texts assessed according to predefined inclusion criteria. Studies were eligible if they examined risk factors for primary arteriovenous fistula failure in adult patients on hemodialysis. A total of 38 studies were included in the systematic review. Early arteriovenous fistula failure was significantly associated with a distal location of the fistula, small arterial diameter, small vein diameter, low serum albumin level, female gender, diabetes mellitus, and decreased systolic and diastolic blood pressure. This systematic review identified several key risk factors for early arteriovenous fistula failure in patients with end-stage renal disease (ESRD) undergoing hemodialysis. These factors should be considered from a patient safety perspective and included in the shared decision-making process with patients who are candidates for arteriovenous fistula surgery. Optimizing these factors may enhance fistula maturation and reduce the need for repeat vascular access procedures. However, recognizing that some risk factors may not be readily modifiable in ESRD patients, clinicians should balance optimization efforts with the urgency of establishing vascular access.

The Single Cell Landscape of the Human Vein After Arteriovenous Fistula Creation and Implications for Maturation Failure.

Predictors of maturation failure in arteriovenous dialysis access.

Objective-Surgically created upper extremity arteriovenous fistulae (AVF) are the preferred vascular access for patients requiring dialysis. It is estimated, however, that 50% of AVF fail within one year due to aggressive neointimal hyperplasia, which significantly increases morbidity and mortality. Matrix metalloproteinase-3 (MMP-3), also known as stromelysin-1, is a member of the metalloproteinase family that plays a critical role in the pathogenesis of many human disorders by degrading extracellular matrix and regulating molecular signaling pathways. The role of MMP-3 in AVF neointimal failure has not been explored.Approach and Results-We observed that MMP-3 was induced in a time-dependent fashion by fetal bovine serum (FBS) and the growth factor PDGF-BB in cultured venous SMC. MMP-3 was also highly expressed in the neointimal SMCs of the outflow veins and the juxta-anastomotic area in an AVF mouse model, as well as in human AVF specimens. Knockdown of MMP-3 significantly suppressed venous SMC proliferation, whereas overexpression of MMP-3 facilitated cell growth in vitro. Importantly, deficiency of global and SMC-specific MMP-3 significantly reduced neointimal hyperplasia and improved patency after AVF creation. Mechanistic studies showed that MMP-3-mediated SMC proliferation and AVF neointimal hyperplasia were regulated via the FAK-AKT signaling pathway.Conclusions-These data suggest that MMP-3 is a key mediator of AVF neointimal failure. Targeting local MMP-3 activity may be a novel therapeutic strategy to prevent AVF neointimal failure and improve outcomes in patients requiring hemodialysis.

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.

Risk factors for early arteriovenous fistula failure in patients undergoing hemodialysis and comparison of diagnostic prediction models.

Endovascular salvage of early failure of arteriovenous fistula by transradial arterial and retrograde venous fistuloplasty and stenting.

Intimal hyperplasia (IH) compromises the patency of arteriovenous fistula (AVF) vascular access in patients with end-stage kidney disease. Uncontrolled cell proliferation and migration, driven by inflammation, shear stress and surgery, are well-known triggers in IH. Recently, microRNAs (miRNAs) have emerged as regulators of core mechanisms in cardiovascular diseases and as potential markers of IH. This study was aimed at identifying a specific miRNA panel in failed AVFs and clarifying the miRNA involvement in IH. miRNA profiling performed in tissues from patients with IH (AVFs) and normal veins (NVs) highlighted a subset of four miRNAs significantly deregulated (hsa-miR-155-5p, hsa-miR-449a-5p, hsa-miR-29c-3p, hsa-miR-194-5p) between the two groups. These miRNAs were analyzed in tissue-derived cells (NVCs and AVFCs), human aortic smooth muscle cells (HAOSMCs) and human umbilical vein endothelial cells (HUVECs). The panel of hsa-miR-449a-5p, hsa-miR-155-5p, hsa-miR-29c-3p and hsa-miR-194-5p was up-regulated in AVFCs, HAOSMCs and HUVEC under inflammatory stimuli. Notably, overexpression of hsa-miR-449a-5p exacerbated the proliferative, migratory and inflammatory features of AVFCs. In vitro pharmacological modulation of these miRNAs with pioglitazone, particularly the down-regulation of hsa-miR-155-5p and hsa-miR-29c-3p, suggested their involvement in IH pathogenesis and a potential translational application. Overall, these findings provide new insights into the pathogenesis of AVF failure, reinforcing the miRNA contribution to IH detection and prevention.

Problem statementVascular Access (VA) in hemodialysis (HD) patients is vital for treatment efficiency and is influenced by Egypt’s healthcare system and socioeconomic factors. It is a complex issue, shaped by both challenges and opportunities within the nation’s healthcare infrastructure.AimTo examine trends in VA use and associated characteristics in patients on HD based on data from a nationwide survey in Egypt.MethodsThis cross-sectional study targeted patients on maintenance hemodialysis across Egypt, using stratified cluster sampling from 11 representative governorates. Medical personnel collected data using a structured electronic Google Form questionnaire, which gathered data on patient demographics, clinical details, VA creation and complications, and healthcare access.ResultsThe study included 3,582 chronic HD patients. Data were collected over a one-year period from May 2023 to May 2024. An arteriovenous fistula (AVF) was the initial VA for 669 patients (18.7%), while a temporary catheter was used as the initial access in 2,861 patients (79.9%). AVF thrombosis was the primary cause of AVF failure, occurring in 69.7% of cases. Pre-HD VA creation was associated with substantially better fistula maturation, fewer VA numbers, and lower VA-related complications.ConclusionSignificant regional and sociodemographic variations in VA practices were observed across Egypt. The findings revealed persistent reliance on temporary catheters at HD initiation, with encouraging but limited progress in pre-HD AVF planning. These trends underscore the need for early referral strategies and targeted interventions to optimize vascular access outcomes nationwide.

Abstract Arteriovenous fistula (AVF) failure remains a significant challenge in the treatment of end-stage renal disease, leading to increased morbidity and economic burden to the patients. The availability of effective devices to address AVF is still very limited globally. In view of the high failure rate of AVF during hemodialysis, development and selection of most appropriate material for AVF device is a test for the researcher. In the present research work, the mechanical and biocompatibility tests have been conducted on the implant grade silicon materials selected to develop the device before it is subjected to animal trials. The AVF assisting device is fabricated and a custom-designed in-vitro model is developed to replicate the human anatomical surroundings. The tensile strength and the elongation of the selected implant-grade silicon in the fabricated device are tested using a universal testing machine; also, the surface structure and the chemical composition are tested using scanning electron microscopy (SEM) and Fourier transform infrared spectroscopy (FTIR) respectively. The hydrophilicity and long-term performance are analyzed using a water absorption test. The biocompatibility and cytotoxicity of the material and fabricated device are determined using cell viability assay. It is observed that the silicone material used in the AVF assisting device shows strong mechanical integrity, optimum structural stability, biocompatibility and is non-cytotoxic to mammalian cell line. Thus, it can be concluded that the implant-grade silicone material is a potential candidate for the design and development of AVF assisting device due to its observed sustainability and biocompatibility.

A comprehensive understanding of arteriovenous fistula US evaluation and common sites of arteriovenous fistula failure is helpful to guide intervention such as assisted maturation, treatment of focal stenoses, and declotting.

Background: Arteriovenous fistulas (AVFs) remain the gold standard for hemodialysis access in end-stage renal disease (ESRD) patients. However, AVF failure, whether due to thrombosis, stenosis, or maturation failure, poses significant challenges in clinical nephrology and vascular surgery. This review examines the factors influencing AVF salvageability, durability, and probable loss, while evaluating contemporary management strategies. Methods: A systematic analysis of peer-reviewed literature was conducted, focusing on AVF patency rates, surgical revision techniques, endovascular interventions (angioplasty, stenting, thrombolysis), and predictors of long-term functionality. Results: Studies indicate that early detection of AVF dysfunction and prompt intervention significantly enhance salvage rates. Factors such as venous stenosis, inadequate inflow, and patient comorbidities (diabetes, atherosclerosis) critically impact AVF longevity. Endovascular approaches demonstrate high initial success, but surgical revision may offer superior durability in select cases. Conclusion: Optimizing AVF survival requires a multidisciplinary approach, integrating surveillance protocols, timely interventions, and patient-specific risk stratification. Further research is needed to refine predictive models for AVF loss and improve minimally invasive salvage techniques.

Pseudoaneurysm formation at the site of arteriovenous fistula (AVF) poses a significant threat to vascular access patency in patients undergoing hemodialysis. Management of such complications is particularly challenging in patients with a history of multiple AVF failures. A 27-year-old patient with end-stage renal disease on maintenance hemodialysis for 2 years presented with a rapidly enlarging mass (5 × 5 × 4 cm) and local skin changes at the site of a previously created radial artery-basilic vein AVF. The patient had a history of multiple AVF thromboses and redo reconstructions. Duplex ultrasound confirmed a pseudoaneurysm involving the outflow vein on the forearm. Surgical management included excision of the outflow vein with the pseudoaneurysm, mobilization of collateral vein, creation of an end-to-end anastomosis between this vein and part of normal outflow vein and creation of an end-to-side anastomosis between the basilic vein and the brachial vein to ensure adequate outflow and minimize the risk of recurrent thrombosis. The postoperative course was uneventful, and the patient was discharged on the fifth postoperative day. Dialysis via the reconstructed vascular access was resumed 2 months after surgery and has remained functional for over 18 months without complications or limitations. This case highlights the importance of individualized and complex surgical approaches for the management of AVF pseudoaneurysms. Timely and tailored interventions can preserve vascular access and maintain quality of life, even in patients with complex vascular histories.

Vascular access failure often makes hemodialysis treatment inefficient or impossible. This study investigates the potential of using recordings and acoustic analysis of arteriovenous fistula (AVF) sounds to i) distinguish between AVFs suitable for routine cannulation and those that are unsuitable and ii) detect possible complications in functional AVFs early. A total of 154 AVF sounds were recorded and classified into functioning and non-functioning groups. Functioning AVFs were further categorized as optimally patent or as having complications like stenosis or aneurysm, based on ultrasound. After audio pre-processing, the high-low peak ratio (HLPR) and its natural logarithm (ln(HLPR)) were calculated using peak amplitudes in low and high-frequency ranges (100-250 Hz and 500-700 Hz respectively). The results revealed significant differences in acoustic metrics between functioning and non-functioning AVFs. Non-functioning AVFs exhibited higher frequency sounds, higher HLPR and ln(HLPR), and reduced amplitude in the low frequency range. In functioning AVFs, the presence of stenosis produced distinct acoustic patterns with higher frequencies and lower amplitude in the low-frequency range, while aneurysms exhibited prominent high frequencies but did not significantly affect acoustic metrics compared to sound recordings from optimally patent AVFs. Optimally patent AVFs had the highest amplitude in low frequency and the lowest high-frequency presence, exhibiting statistically significant differences compared to stenotic and non-functioning AVFs. Additionally, exploratory ROC analysis suggests a potential threshold in ln(HLPR) for identifying AVF function impairment, with good sensitivity and specificity. This study highlights the transformative potential of AVF sound analysis as a tool for identifying AVF complications and failure. By using the unique acoustic characteristics of AVFs, clinicians can improve their surveillance strategies, providing patients with timely interventions and better outcomes.