December 12, 2008

Upgrading Small Caliber Veins (< 3mm) for Arteriovenous Fistulas: Primary Balloon Angioplasty plus Balloon Angioplasty Maturation

Lorena P. De Marco Garcia, MD, Luis R. Davila-Santini, MD, Feng Qin, MD, Julio Calderin, MD, Kambhampaty Krishnasastry, MD, Thomas Panetta, MD.
North Shore LIJ Health System, Manhasset, NY, USA.

Objective: Small diameter veins are often a limiting factor for successful creation of arteriovenous fistulas (AVFs). Autologous fistulas were created using primary balloon angioplasty (PBA) to upgrade small diameter veins. DOQI guidelines are requiring 60% primary fistulas by 2009.

Methods: 41 patients underwent PBA with an intent-to-treat using an all-autologous policy. PBAs were performed in all patients during AVF creation using 2.5mm to 4mm angioplasty balloons (1 mm to 1.5 mm larger than nominal vein diameter) prior to creation of the anastomosis. PBAs were performed through the spatulated end of the vein utilizing hydrophilic guidewires and hand inflations without fluoroscopy. All patients underwent sequential balloon angioplasty maturation (BAM) performed 4, 6 and 8 weeks after the PBA. Success was determined as the ability to utilize the fistula for hemodialysis without revision.
Results: Thirty-three of 41 patients maintained patency prior to the initial BAM. Of the eight patients that thrombosed, six were salvaged by using lytic technique, thrombectomy and sequential BAM. Two patients could not be salvaged and required AVGs. One AVF was ligated for steal-syndrome and an alternative site AVF was placed. Thirty-eight of the AVFs were functional. Only two patients required a new indwelling catheter. Based on intent to treat, 92.7% of fistulas using suboptimal veins were functional and used for dialysis.
Conclusions: Small or suboptimal veins can be matured achieving greater than 90% autogenous AVF rate utilizing PBA and BAM. Most immature AVF require sequential BAM and surveillance. The use of these techniques decreases the number of patients requiring AVGs and indwelling catheters.

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