Endovascular Fistula Creation

The quest for a less invasive and potentially superior access has led to the pioneering of endovascular (eAVF) and percutaneous (pAVF) arteriovenous fistulas in the past few years. 2018 saw two devices clear the Food and Drug Administration for use. Compared to their surgical arteriovenous fistula (sAVF) counterparts, they allow operators with endovascular skills to create fistulas without traditional incisions and operative techniques. Their introduction has expanded who can create fistulas rather than simply maintain them. As a relatively new technology (particularly considering the COVID-19 pandemic limiting some procedures), there are limited experiences comparing sAVFs to pAVFs and eAVFs with no randomized trials. The WavelinQ™ (eAVF) (Becton Dickinson, Franklin Mills, New Jersey) is a 4F two catheter endovascular system which uses radiofrequency energy to make a direct connection between the ipsilateral radial artery and radial vein or ulnar artery and ulnar vein. The flow from the deep system then is transmitted to the superficial system via the perforating vein located near the antecubital fossa in most and then fills either the cephalic vein and/or the basilic vein (via the median cubital vein). The anastomosis is a side-to-side anastomosis completed by an access in the upper extremity artery and vein with fluoroscopic guidance, often followed by coil embolization of one of the deep outflow veins (usually brachial) to preferentially divert flow to the superficial system and allow two needle cannulation. While data are still incomplete due to the recent development of this procedure, a recent aggregated analysis reported technical success ranges from 96% to 100%, maturation rates of 87.4% at 6 months, time to maturation averaging 41 days, and 6 month primary and secondary (cumulative) patency rates 71.9% and 87.8%, respectively with less than 0.6 interventions per year.