Endovascular Management of the “Failing to Mature” Arteriovenous Fistula

The “failing to mature” arteriovenous fistula (AVF) is frequently encountered among patients in need of hemodialysis (HD). It is essential that its prompt recognition and management are conducted in a timely manner to allow its use in HD. The physical examination is essential in early identification of the “failing to mature” AVF and helps guide initial endovascular management. In most instances, endovascular evaluation successfully identifies all the lesions that have contributed to AVF derangement and retarded its proper maturation. It is common to find juxta-arterial stenosis as well as venous stenosis in the body of the AVF, or its venous outflow tract. However, a wide spectrum of lesions can be seen, and in many instances, multiple lesions coexist in the same deranged AVF. Identifying and understanding the impact of all the lesions is a prerequisite for any intervention. Balloon angioplasty is the mainstay of management of stenotic lesions. Accessory vein obliteration or ligation is necessary in some cases. Procedure-related complications are low and are reduced by caution and experience. Overall, endovascular management is successful in converting the “failing to mature” AVF to usable HD access in the majority of cases, but multiple interventions may be needed in some before the AVF can be used for HD. Once usable, these AVFs have good long-term assisted patency rates. When endovascular management is unsuccessful or not possible, surgical revision of the AVF, or creation of a new AV vascular access is necessary.