Intraoperative angioplasty during the preparation of arteriovenous fistulas

Abstract

Purpose Autogenous arteriovenous fistula (AVF) has been shown to be the preferred vascular access in patients that are candidates for chronic haemodialysis, due to the superiority of this technique compared with catheter access or prosthetic graft in terms of patient mortality and morbidity. According to the K/DOQI guidelines, the wrist (radio-cephalic) primary AVF is the first in order of preference. In recent years, leading centers approached primary intraoperative ultrasound-guided percutaneous angioplasty (ITA), an endovascular procedure that can be performed in certain conditions during AVF creation and that uses the arterial or venous incision to introduce the requested devices. Our work aims to show the outstanding potential of ITA for improving the pool of candidates for autologous vascular access for hemodialysis. Methods We describe the clinical and ultrasonographic conditions requiring ITA, our standardized techniques for venous and arterial procedure and the suggested timing for follow-up. Thereafter, we propose an analysis of the studies published on the topic, identifying relevant clinical cases and reporting access and patient survival data. Results The reported studies are predominantly observational ones and show satisfactory clinical results in patients treated with ITA regarding the outcomes early failure and failure to mature. A randomized study including patients with venous vessels showing a caliber of less than 2 cm indicated significantly better results in the ITA group compared to controls. Conclusions According to the published data and based on our experience, ITA can be considered an effective, cost-saving, and simple procedure allowing AVF creation from otherwise unsuitable vessels.