Avoiding Early Failure in Arteriovenous Fistulas

An arteriovenous fistula (AVF) is the preferred choice for hemodialysis access in most patients. AVFs are associated with lower morbidity, mortality, and cost profiles when compared with AV grafts and particularly with central venous catheters. Early failure (EF) rates have been reported as high as 20–50% and include early thrombosis or non-maturing AVFs. The rate of AVF-EF significantly impacts the overall success of autogenous access performance and decreases cost effectiveness. Risks for EF include diabetes, female gender, distal radial cephalic access site, diabetes, and surgeon experience. We review two broad categories of AVF-EF: immediate postoperative thrombosis (generally due to technical or operative site selection errors) and failure to mature. We discuss the multiple radiocephalic-AVF options available and technical considerations for success. When a distal-AVF is not expected to mature promptly, our next recommendation is a proximal radial artery-AVF. We review AVF failure to mature and lack of early recognition for needed intervention, both key elements in avoiding higher rates of AVF-EF. Safe and functional AVFs can be created while avoiding most EFs. Minimizing early access failure will dramatically improve overall outcomes and cost effectiveness for autogenous access in the United States.