Reliability of preoperative venous mapping ultrasound in predicting autogenous arteriovenous fistula maturation
El Khoury R, Russeau AP, Patel N, Dabbous F, Kechker I, Lipatov S, Ostrovski T, Jacobs CE, White JV, Schwartz LB. Reliability of preoperative venous mapping ultrasound in predicting autogenous arteriovenous fistula maturation. J Vasc Surg. 2020 Oct 19:S0741-5214(20)32273-4. doi: 10.1016/j.jvs.2020.09.035. Epub ahead of print. PMID: 33091513
BACKGROUND: Autogenous arteriovenous fistula creation is the preferred route for vascular access for hemodialysis. While preoperative venous mapping ultrasound has been advocated as an operative planning adjunct, and recently incorporated in the Society of Vascular Surgery clinical guidelines, controversy remains as to its usefulness for predicting access success. The purpose of this retrospective clinical study was to test the hypothesis that vein size measured on routine preoperative venous mapping is a poor predictor of primary fistula maturation.
METHODS: Consecutive upper extremity autogenous arteriovenous fistulas created by three dedicated vascular surgeons were retrospectively reviewed. Demographic characteristics, pre-operative venous mapping, functional maturation, and patency were analyzed. Clinically relevant variables were tested for predictive significance using a logistic regression model.
Results: A total of 199 upper extremity autogenous arteriovenous fistulas had been created during a 5-year period. Patients were aged 70 ± 16 years (range, 20-96 years), and 62% were men. Most had already been undergoing dialysis before fistula creation (83%), usually via a tunneled central venous catheter (62%). Radial-cephalic, brachial-cephalic, and brachial-basilic arteriovenous fistulas had been created in 82 patients (41%), 76 patients (38%), and 10 patients (5%), respectively. Fistula maturation, defined as a palpable thrill and/or successful cannulation of the fistula with the ability to deliver a flow rate of 400 mL/min, was achieved in 67% of the patients. A higher body mass index was associated with nonmaturation on both univariate and multivariate analyses (success, 28.6 ± 7.7 kg/m2; vs failed, 31.6 ± 9.4 kg/m2; P = .029; odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02-1.10; P < .01). On univariate analysis, the maximum target vein diameter assessed by preoperative venous mapping was slightly larger in the group achieving successful maturation (2.9 ± 1.1 mm vs 2.6 ± 0.9 mm; P = .014). However, neither the maximum target vein diameter nor a target vein size >3 mm was significantly predictive of maturation on multivariate analysis (maximum vein diameter: OR, 0.65; 95% CI, 0.35-1.22; P = .176; vein size >3 mm: OR, 0.91; 95% CI, 0.32-2.60; P = .857). After a median follow-up of 15 months (interquartile range, 26 months), the primary functional patency, primary-assisted patency, and secondary patency rates were 39.1% ± 0.6%, 94.5% ± 0.6%, and 97.9% ± 0.5%. No association of vein diameter with long-term patency was found.
Conclusions: Despite the national fistula-first initiatives, most patients still undergo access via catheter at the initiation of hemodialysis. The use of routine preoperative venous mapping does not predict successful primary maturation. Also, no clinically useful predictor of fistula maturation was identified in the present study.