Balloon Angioplasty Maturation Of Arteriovenous Fistulae: A New Paradigm For Surveillance, Maintenance And Improved Function

Timothy Wu¹, J. Timothy Riley¹, Gregg Miller², Rafik Moufid¹, Gaurav Chandra¹, Frank Tarantini¹, William Rodino¹, Thomas Panetta.^1
1Staten Island University Hospital, Staten Island, NY; ²American Access Care, Brooklyn, NY.

OBJECTIVES: Balloon angioplasty maturation (BAM) has emerged as a novel technique to increase the utilization of primary arteriovenous fistulas (AVFs) for access, to shorten the time to clinical usefulness, and to salvage clinically non-maturing AVFs. BAM of AVFs utilizes staged, sequential angioplasties to significantly increase fistula diameters.

METHODS: 703 BAMs were performed in 293 patients with AVFs from July 2004 until December, 2006. In approximately 80% of cases, BAMs were performed on small, unusable fistula and 20% were primarily performed to facilitate and shorten maturation times. Technical aspects included staged, sequential balloon angioplasty of the entire AVF over 6-8 weeks, inflow angioplasty, outflow angioplasty, flow rerouting of forearm AVFs into the basilic system, coil embolization of collateral veins, and limited controlled extravasation of over-dilated vein segments. Technical successful was defined as achievement of a functioning AVF for hemodialysis access. Once patients achieve a functionally useful AVF they underwent routine surveillance with fistulagram, angioplasty, stenting as needed, for maintenance of patency.

RESULTS: Of 293 patients undergoing BAM, 281 (95.9%) had technical success, achieving a useful AVF. However 29 patients (9.9%) ultimately required alternative methods for access. 28 patients (9.6%) underwent a single BAM. 86 patients (29.4%) underwent two staged BAMs from two to four weeks apart. 169 patients (57.6%) underwent three staged BAMS and 10 patients (3.4%) underwent four staged BAMs. Follow-up of patients for up to three year has resulted in a primary patency of over 90%. There has been no pseudoaneurysm formation in AVF undergoing BAMs.

CONCLUSIONS: BAM maturation of AVFs is a new concept and procedure that facilitates the utilization of AVFs and increases the ability to utilize smaller veins for AVFs. . Fistulas are matured quicker with the advantages of shorter indwelling catheter times, increased blood flow and prolonged patencies. Larger diameter fistulas (up to 4 times baseline diameter) facilitate cannulation and may reduce cannulation related complications such as extravasation and pseudoaneurysm formation. Three year results, technical considerations and methodology for these techniques are presented.