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The Efficacy of Patch Angioplasty for Maturation of Arteriovenous Fistulas
Courtney Grant, MD1, Elias Kfoury, MD1, Dipankar Mukherjee, MD1, Homayoun Hashemi, MD2.
1Inova Fairfax Hospital, Falls Church, VA, USA, 2Inova Fair Oaks Hospital, Fairfax, VA, USA.

Objective(s):
Given the better patency rate of arteriovenous (AV) fistulas and the decreased risk of infection compared to arteriovenous grafts, the Kidney Disease Outcomes Quality Initiative guidelines recommend the fistula first approach. Unfortunately about 23-46% of fistulas fail to mature. Our objective is to describe and review the effectiveness of bovine pericardial patch angioplasty, a novel secondary procedure that can help mature arteriovenous fistulas. Bovine pericardial patch angioplasty increases the surface area of the vein and ensures adequate lumen size for dialysis.
Methods:
A retrospective review was performed of all patients with AV fistulas that failed to mature who underwent bovine pericardial patch angioplasty from March 2007 to December 2015. Medical records were examined for operative details, fistula follow up and demographic factors. A follow-up phone call was also attempted for each patient to determine fistula function. All procedures were performed by a single surgeon with or without resident assistance.
Results:
Patch angioplasty was performed on 110 patients with nonmaturing fistulas. Ninety-five patients were able to be followed up via phone call or medical records. Of these 95 patients, 80 (84.2%) were eventually able to use their fistula for hemodialysis while 9 (9.5%) were never able to be accessed, and 6 (6.3%) matured but were never needed. At one year, 68.8% of those utilizing their fistula remained patent-- 60% without any further intervention, or primary patency after patch angioplasty. The remaining 40% with assisted primary patency required further intervention due to stenosis proximal or distal to the patch. Complications included 3.5% thrombosis within the first month, 2.7% infection rate over the lifetime of the access, and one patient required return to the operating room for drainage of infected hematoma with subsequent removal of the patch. For patients requiring post-patch intervention within one year there was a 9 month average time to intervention.
Conclusions:
Bovine pericardial patch angioplasty can be performed safely on nonmaturing fistulas with good one-year secondary maturation and patency rates. However, due to the possibility of stenosis proximal or distal to the patch requiring subsequent procedures to maintain patency, it is critical that these patients be followed closely with interval ultrasound evaluation.


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