REVIEW ARTICLES

Richard P. Cambria, MD, Section Editor

Factors affecting the patency of arteriovenous

fistulas for dialysis access
George E. Smith, MBBS, MRCS, Risha Gohil, MBChB, MRCS, and
Ian C. Chetter, MBChB, FRCS, MD, Hull, United Kingdom

Background: The autologous arteriovenous fistula (AVF) is the accepted gold standard mode of repeated vascular access
for hemodialysis in terms of access longevity, patient morbidity, and health care costs. This review assesses the current
evidence supporting the role of various patient and surgeon factors on AVF patency.
Methods: The literature was searched to identify the current evidence available for patient characteristics, methods of AVF
planning, and anatomic factors that may affect patency outcomes after AVF formation. The use of adjuvant medications,
surgical techniques, and policies for AVF maintenance are discussed in relation to AVF patency.
Results: Current literature supports patient factors, such as increasing age, presence of diabetes, smoking, peripheral
vascular disease, predialysis hypotension, and vessel characteristics, as directly influencing AVF patency. Vessels of small
caliber (<2 mm) or demonstrating reduced distensibility are unlikely to create a functional AVF. Current evidence does
not support altered patency due to sex or raised body mass index (<35 kg/m2). Factors such as early referral for AVF,
preoperative ultrasound vessel mapping, use of vascular staples, and intraoperative flow measurements affected AVF
patency, but the use of medical adjuvant therapies did not. Programs of surveillance and various needling techniques to
maintain patency are not supported by current evidence. Novel techniques of infrared radiotherapy and topical glyceryl
trinitrate are possible future strategies to increase AVF patency rates. The limitations of available evidence include a lack
of large, randomized controlled trials and meta-analysis data to support current practice.
Conclusions: There is a complex interaction of factors that may affect the patency of an individual AVF. These need to be
carefully considered when selecting surgical site or technique, adjuvant treatments, and follow-up protocols for AVFs.
( J Vasc Surg 2012;55:849-55.)

The advent of hemodialysis in the mid-20th century
gave rise to a need for reliable, repeated access to the
circulation. Brescia and Cimino published their landmark
report describing hemodialysis through an autologous ar-
teriovenous fistula (AVF) in 1966, vastly reducing the
problems of infection and thrombosis that plagued the
previously described long-term cannulation methods and
external shunts.1 The autologous AVF has since been
widely accepted as the optimal access method for hemodi-
alysis as measured by lower morbidity and mortality figures
and reduced maintenance costs. This review summarizes
From the Academic Vascular Surgery Unit, Hull and York Medical School.
Competition of interest: none.
Reprint requests: George E. Smith, Academic Vascular Surgery Unit, Hull
and York Medical School, Level 1, Tower Block, Hull Royal Infirmary,
Hull and East Yorkshire Hospitals NHS Trust, Hull, HU3 2JZ, UK
(e-mail: george.smith@hey.nhs.uk).
The editors and reviewers of this article have no relevant financial relationships
to disclose per the JVS policy that requires reviewers to decline review of any
manuscript for which they may have a competition of interest.
0741-5214/$36.00
Copyright © 2012 by the Society for Vascular Surgery.
doi:10.1016/j.jvs.2011.07.095
the evidence to date regarding factors that can affect fistula
patency.
METHODS
We performed a search of published literature in Octo-
ber 2010 using the Medline (1966 to October 2010),
Embase (1980 to October 2010), CINAHL (1982 to
October 2010), and Cochrane Library research databases.
The following search terms were used: haemodialysis or
hemodialysis or dialysis or kidney failure or kidney disease
or arteriovenous fistula or arteriovenous shunt or access or
vascular access, or angio access and survival or patency or
outcomes.
These search results were further combined with a
search performed for each of the subheadings below, in-
cluding alternate spellings. Any studies identified as de-
scribing or possibly describing factors affecting patency or
outcome for autologous AVFs for hemodialysis in adults
were reviewed and their reference lists searched for further
relevant studies. Reports were ranked according to design
by the Centre for Evidence-Based Medicine (Oxford) scale,
and data from the highest-ranked evidence available are
included in this review. Where this evidence was contradic-
849
 JOURNAL OF VASCULAR SURGERY
850 Smith et al March 2012

Table I. Summary evidence levels and evidence limitations of available evidence identified for each nonmodifiable factor
discussed

Best evidence suggests

Nonmodifiable factor Level of best evidence effect on patency Limitations

Increased age Meta-analysis2 Yes Meta-analysis of RC AVF only

Female sex Meta-analysis5 No
Diabetes Prospective series6,7 Yes Effect reduced in proximal AVF and with imaging
Hypotension Prospective series12,13 Yes Diastolic pressure only
Artery diameter Meta-analysis28 Yes Reduced patency of artery
Arteriosclerosis Prospective series29,30 Yes Increased failure risk with increased IMT and reduced ABPI
Arterial low Prospective series31-33 Yes Higher RI or a reduced increase in PSV correlate with
poorer AVF flow and secondary patency
Venous diameter Meta-analysis28 Yes Lower limit of 2 mm suggested for wrist RC AVF; no
agreed figures for other sites
Venous distensibility Prospective eries31,34 Yes DUS assessments are poorly reproducible
ABPI, Ankle-brachial pressure index; AVF, arteriovenous fistula; BMI, body mass index; DUS, duplex ultrasound IMT, intima-media thickness; PSV, peak
systolic velocity; RC, radiocephalic; RI, resistive index.

Table II. Summary of evidence levels and evidence limitations for potentially modifiable factors discussed

Best evidence suggests

Modifiable factor Level of best evidence effect on patency Limitations
8-11
Smoking Prospective series Yes Negative effect on patency in smokers
Obesity (BMI ⬎30) Prospective series14 No Evidence of effect seen in BMI ⬎35
“Early” referral Retrospective series18 Yes No evidence of optimal timing of referral
Ultrasound imaging RCT19-21 Yes RCT evidence not applicable to majority of patients
Anastomosis type RCT36 Yes End to side (or functional end to side) preferred
Vascular staples/clips Prospective series37,38 Yes
Flow assessments Prospective series39,40 Yes Can be used as prognostic tool or prompt re-evaluation in
Antiplatelet therapy Systematic Yes/o short-term benefit but paucity of data/largest trial
review/RCT41,42 found reduced thrombosis rate but no effect on
cumulative patency
Systemic heparin use RCT (see Table III) No Evidence suggests increased risk of bleeding with heparin
given systemically
44
GTN patch therapy Controlled experiment Potential for effect Evidence of acute effect on AVF size and flow, no
evidence of effects on patency
Far infrared therapy RCT45 Yes Single RCT evidence
Timing of first cannulation Prospective observational Yes Cannulation before 14 days reduces patency rates
46
study
Cannulation technique Cohort studies50 No Limited data suggest shift in types of complications; no
specific data regarding patency
52,53
Surveillance Meta analysis No AVF cumulative patency does not appear to be improved
by surveillance
AVF, Arteriovenous fistula (autologous); AVG, arteriovenous graft (prosthetic); GTN, glyceryl trinitrate; RCT, randomized prospective controlled trial.

tory or contentious, the review also includes data from
lower-ranked publications. The best available level of evi-
dence for each factor reviewed is summarized in Table I and
Table II.
RESULTS
Patient factors
Patient factors may affect the outcomes of a newly
formed AVF, and those that can be modified should be
addressed where possible. Factors that cannot be modified
may influence the choice of site or surgical technique for
AVF creation.
Age. Age could conceivably increase risk by an in-
creased incidence of comorbidities (peripheral vascular dis-
ease, diabetes, etc). A meta-analysis of 13 cohort studies (of
which 11 were retrospective) provides the best available
evidence, concluding that wrist radiocephalic AVFs
(RCAVFs) had an increased primary failure rate and re-
duced patency in elderly patients at all time points.2 How-
ever, the definitions of “elderly” in the included studies
ranged from 50 to 70 years, and the review was specific to
wrist AVFs. Subsequent studies have reported conflicting
findings for the effects of patient age on outcome.
Sex. In the Hemodialysis (HEMO) Study, female sex
was identified as a significant predictor of graft rather than
AVF use,3 but there is little specific evidence for AVF
patency differences between sexes. Women may present
with smaller-caliber arteries and may therefore be expected
to have lower AVF patency rates than men. However,
Caplin et al4 showed that arterial and venous diameters
JOURNAL OF VASCULAR SURGERY
Volume 55, Number 3
were not significantly different between men and women.
Subsequent meta-analysis data suggest that women have
similar maturation and 1-year patency rates as men for
RCAVFs.5
Diabetes. Many centers have reported increased use of
prosthetic material for grafts in diabetic patients compared
with nondiabetic patients in their dialysis populations. De-
spite this, literature shows evidence of satisfactory AVF
outcomes in diabetic patients.6,7 Sedlacek et al6 reported
that despite increased arterial calcification, vessel diameters
and arterial peak systolic volume were not significantly
different between diabetic and nondiabetic patients in their
population. Subsequent AVF formation in their diabetic
patients was effective, and outcomes were similar regardless
of the presence of diabetes. Konner et al7 reported in-
creased use of proximal fistulas in diabetic patients but with
primary access survival similar to that of nondiabetic pa-
tients. Secondary survival at 24 months was reduced com-
pared with nondiabetic subjects, however, and steal syn-
drome was more common in the diabetic group.
Functional maturity rates for AVFs in diabetic patients have
been suggested to be increased by the use of routine vessel
mapping.7 As such, the effects of diabetes on overall AVF
outcomes may be minimized by careful preoperative vessel
imaging and AVF site selection.
Smoking. Tobacco smoking is a well-known risk fac-
tor for vascular disease and arteriosclerosis. The direct link
to AVF failure was first described by Wetzig et al,8 who
reported a significantly higher incidence of early and late
fistula failure in patients who were cigarette smokers, find-
ings that have since been confirmed by other studies.9-11
Hypotension. Postdialysis hypotension with reduced
flow through the AVF may be related to poor outcome.
Culp et al12 specifically described predialysis diastolic pres-
sure as a predictor of risk of thrombosis in AVFs and grafts
in the first year after formation. A subsequent prospective
series of 463 patients also reported that a low mean diastolic
pressure correlated with poorer AVF survival after exclusion
of patients with early fistula failure from the study.13 Sys-
tolic pressure has not been reported to relate to access
survival.
Body mass index. Obesity is defined as body mass
index (BMI) ⬎30 kg/m2. Some surgeons have previously
avoided AVF use in favor of grafts in obese patients, argu-
ing that even superficial veins in this group may be too deep
to form useable AVFs without “superficialization” or local
liposuction over the fistula.
Superficial veins are often not clinically apparent in
obese patients, and the use of preoperative imaging may
have a significant effect on the incidence, site, and patency
of AVFs in this group. A trial that used routine preoperative
imaging to compare AVF outcomes in patients with a BMI
⬎27 vs ⬍27 kg/m2 found no difference in rates of obtain-
ing an AVF suitable for hemodialysis between the two
groups.14 Furthermore, Chan et al15 examined AVF out-
comes for 1486 hemodialysis patients and compared those
with a BMI ⬍30 vs ⬎30 kg/m2 but were unable to confirm
BMI as a factor in predicting AVF revision or failure. An
Smith et al 851
increased risk of failure to mature was identified for those
patients with BMI ⬎35 kg/m2.
A small number of case reports have suggested that
excessive soft tissue compressing venous outflow may di-
rectly lead to failure in extremely obese patients.16 The
evidence suggests that only “super obesity” affects AVF
patency and that good results can be achieved in obese
patients with awareness of specific factors (outflow occlu-
sion, need for superficialization procedures) and careful
preoperative assessment of vessels.
Preoperative period
Timing of referral for AVF formation. Early referral
to access services improves the number of patients com-
mencing dialysis with an AVF, improves patency, and
avoids potential complications related to central venous
catheter placement.
AVF creation before dialysis is initiated may allow mat-
uration in a biochemical environment preferable to that
present once dialysis has commenced. Uremia and dialysis
itself are associated with increased levels of oxidative stress,
precipitating endothelial dysfunction, neointimal hyperpla-
sia, and AVF stenosis. Samples of brachial vein obtained
during access creation in 15 uremic patients showed signif-
icantly greater intimal and medial widths in patients who
had received ⬎6 months of dialysis compared with those
who had received ⬍6 months of treatment.17 In a cross-
sectional study of 750 AVFs and grafts,18 accesses placed
before commencing dialysis had a lower failure-to-mature
rate and higher patency rate than those placed once the
patient began dialysis.
Duplex ultrasound imaging. Early studies were con-
tradictory regarding the benefits of duplex ultrasound (DUS)
imaging use in AVF planning. Many DUS-detectable aspects
of arterial and venous anatomy correlate with AVF patency
(see below). Assessment of the subclavian waveform with
pulse-wave Doppler also gives an indication of possible
central venous stenosis or occlusion. Two randomized con-
trolled trials have supported the use of DUS imaging over
physical examination (PE) with 75% vs 94.4% and 80% vs
90.3% success rates for PE and DUS imaging, respectively.
However, no sites other than RC at the level of the wrist
were used in either study and only the laterality of site was
determined by DUS imaging. Other significant deficien-
cies in these randomized controlled trials pertain to
outcome measures (palpable thrill at the end of the
procedure), brevity of follow-up, and a very high rate of
loss to follow-up.19,20
Nursal et al21 randomized patients with adequate find-
ings on PE or DUS imaging to AVF surgery and demon-
strated a nonsignificant trend toward increased palpable
thrill at day 1 in the DUS group but no significant differ-
ence in primary or cumulative patency. Wells et al22 re-
corded alteration in planned surgical sites for AVFs due to
DUS findings and also the assessing physician’s perception
of the need for further imaging. Results suggested that
DUS imaging was of little benefit in patients with adequate
PE findings and that clinicians were reliably able to identify

852 Smith et al
the group likely to benefit. These studies suggest that
selected patients with insufficient clinical examination ben-
efit from DUS imaging, but DUS imaging is not needed
when the PE detects adequate vessels. Despite this, many
clinicians still use DUS imaging routinely before AVF
formation, and no trials to date have directly assessed the
use of routine vs selective DUS imaging in AVF planning.
Arterial factors
Diameter. Preoperative imaging should include as-
sessment of the arteries from the subclavian to the wrist to
document anatomic variants, patency, stenosis, and calcifi-
cation. Smaller artery diameters have been associated with
increased nonmaturation rates, but variation in exact min-
imal figures exists.23-26 Present guidelines suggest a mini-
mum diameter of 2 mm for successful AVF creation at the
wrist,27 but agreement on minimal arterial diameters for
other sites is lacking to date. This minimal value is evi-
denced by meta-analysis findings of the fistula success rate
being significantly different between radial artery diameters
⬎2.0 mm (59%) and ⬍2.0 mm (40%).28
Atherosclerosis. The presence of peripheral vascular
disease has been associated with an increased risk of AVF
failure. Modern high-frequency US machines capable of
high-resolution imaging can determine the intima media
thickness (IMT) of small arteries such as the radial artery at
the wrist. Ku et al29 reported that IMT measurements
during preoperative DUS imaging correlated significantly
to histologic measures and, more importantly, to AVF
thrombosis and to inadequacy of an AVF to maintain
dialysis at 1 year. Similarly, ankle-brachial pressure index, a
reliable marker for peripheral vascular disease, had a signif-
icant association with access failure after adjusting for other
variables.30
Flow and hyperemic response. The relationship be-
tween peak systolic velocity (PSV) at rest and AVF out-
comes is not clear. Dynamic measures of the potential for
increased flow have been more closely investigated. By
using spectral Doppler and induction of hand ischemia by
clenching a fist, reactive hyperemia of the arteries of the
forearm can be observed. As the fist is unclenched, an
increase in PSV and a change in flow pattern from triphasic
(high resistance) to monophasic (low resistance) is evident.
This alteration in flow can be quantified as the resistive
index or by the increase in PSV immediately after release:
Resistive index (RI) ⫽ [PSV at rest – EDV at rest]/PSV
during reactive hyperemia, with EDV representing end-
diastolic velocity.
Poor hyperemic response with an RI ⬎0.7 was predic-
tive of immediate AVF failure in one study,31 and a higher
RI or a reduced increase in PSV with hyperemia were
correlated with reduced AVF flow at 3 months and reduced
secondary patency.31,32 The only other report of AVF
patency and change in PSV after fist clenching showed an
increase in AVF adequacy for dialysis only in women.33
JOURNAL OF VASCULAR SURGERY
March 2012
Venous factors
Diameter. Current guidelines suggest minimum ve-
nous diameter of 2 mm for a cephalic AVF at the wrist, and
no agreed minimum measures exist for other sites to date.27
These measures have been evidenced by meta-analysis dem-
onstrating significant differences in fistula success rates
between cephalic vein diameter ⬎2.0 (71%) and ⬍2.0 mm
(29%).28
Distensibility. Venous diameters are variable with po-
sition, hydration status, temperature, and various provoca-
tion methods. Because AVF maturation relies on increasing
venous diameter to allow cannulation, the distensibility of
veins has been investigated as a potential predictor of AVF
success. Malovrh31 reported that the average increase in
venous diameter in AVFs that failed was only 12% com-
pared with 48% in successful AVFs. Further studies using
strain-gauge plethysmography in patients with end-stage
renal failure reported that 100% of patients with venous
distensibility of ⱕ0.50 mL/mm Hg had a nonfunctional
AVF, whereas only 20% of patients with venous distensibil-
ity ⬎0.50 mL/mm Hg had a nonfunctional AVF.34
Elastography is a recently developed technique that
uses high-frequency US to apply mechanical compression
or vibration to tissue and then detects the extent of this
deformation effect. By using simplifying assumptions, the
deformation can be interpreted as representative of the
underlying Young’s modulus or compliance of the tissue.
Biswas et al35 used this technique in assessing vein compli-
ance in the forearm, and early results suggest it may provide
detailed, high-resolution and spatially accurate maps of
vein-wall mechanics.
Intraoperative factors
Anastomosis. Three types of arteriovenous anasto-
motic arrangement can be used to establish an AVF for
dialysis: end-to-end, end-to-side, or side-to-side. Histori-
cally, AVFs were formed as first described by Brescia and
Cimino in their landmark report using a side-to-side anas-
tomosis.1 They stated that postoperative hand swelling was
a common complication. In a randomized controlled study
20 years later, Wedgwood et al36 reported that the inci-
dence of venous hypertension could be markedly reduced
with the use of the end-to-side technique, which has now
become commonplace. Patency in their study was similar
between the groups, and only the incidence of complica-
tions appeared to separate the techniques.
Vascular staples/clips. In recent years, attempts to
reduce anastomotic stenosis have led to the development of
new techniques designed to allow interrupted clipping or
stapling of vessels to increase compliance at the anastomosis
site. Reports of such techniques have so far stated promis-
ing results of improved maturation rates in forearm autol-
ogous AVFs and significantly improved patency at 40
months in interrupted staple anastomoses.37,38
Blood flow measurement. Intraoperative blood flow
measurement, using a transit-time ultrasonic flowmeter,
registering a flow of ⬍120 mL/min, had a positive predictive
JOURNAL OF VASCULAR SURGERY
Volume 55, Number 3
Table III. Results of randomized controlled trials of systemic heparin use in arteriovenous fistula (AVF) surgery.
Stouffer’s Z method results indicate combined significance levels weighted for number of participants
First author Patients Bleeding rate increased
44
D’Ayala (2008) 115
Ravari H (2008)45 198
Bhomi K (2008)46 50
Stouffer Z method (combined P)
value of 91% for early failure in RCAVFs in one study.39
A prior report correlated flows of ⬍200 mL/min with
reduced primary and secondary patency.40 AVFs with low
flows after anastomosis could therefore be identified as “at
risk” and may thus warrant further investigation in the
theatre or by more intensive follow-up regimens.
Adjuvant therapies
Given that the most common mode of AVF failure is by
thrombosis, many investigators have conducted trials of
medications for AVF patients that may reduce thrombus
formation. Others have reported the use of more novel
adjuvant therapies in attempts to increase AVF patency
rates.
Antiplatelets. The use of antiplatelets in maintaining
AVF patency was supported by the Antiplatelet Trialists’
Collaboration report.41 Cochrane Systematic Review find-
ings were generally in favor of antiplatelet therapy; how-
ever, trials show considerable heterogeneity in outcomes,
and many had only very short follow-up periods.42 A more
recent large-scale randomized, double-blind trial of the
effect of clopidogrel taken for 6 weeks after surgery dem-
onstrated a significantly lower rate of AVF thrombosis
compared with placebo.43 This reduction in thrombosis
rate did not, however, alter the rate for achieving an AVF
suitable for dialysis.
Heparin. The benefit of intravenous heparin given
intraoperatively as an anticoagulant to avoid thrombotic
complications during AVF surgery for hemodialysis has
been evaluated in three studies,44-46 with results reported
in Table III. Stouffer’s Z method allows combination of
significance measures for several trials weighted for number
of participants. Application of this method to available trial
results for use of systemic heparin suggests significantly
more frequent perioperative bleeding in patients receiving
heparin without improved AVF patency.
Topical glyceryl trinitrate. Transdermal glyceryl
trinitrate administration has been suggested as a possible
method to increase local blood flow in new AVFs. Akin et
al47 assessed fistula vein diameter in newly constructed
RCAVFs using DUS imaging with a glyceryl trinitrate
patch applied over the fistula. In the study group, diameter
and flows were significantly increased after glyceryl trini-
trate patch placement compared with measures a few hours
earlier (P ⬍ .05) but not in the control group. Increased
flow may affect maturation and early failure rate, but ran-
domized data with follow-up of outcomes are needed to
prove the effects of this therapy on patency.
Smith et al 853
P Patency rate increased P
Yes .008 No .79
No .175 Yes .046
Yes ⬍.01 No .46
Yes ⬍.001 No .1458
Far infrared therapy. Far infrared electromagnetic
radiation has a wavelength beyond that of visible light and
is used to heat objects exposed to infrared radiation without
heating the surrounding air. Lin et al48 used far infrared
during dialysis sessions and reported a significantly reduced
incidence of AVF malfunction and better unassisted pa-
tency of AVFs after 1 year compared with controls. Mech-
anisms suggested relate partly to local tissue warming and
also to improved endothelial function and an antiprolifera-
tive and anti-inflammatory effect of far infrared radiation
therapy, which has been documented in animal studies and
early human trials.48
Postoperative period
Once created, autologous access continues to require
ongoing input from many members of the multidisciplinary
team. Aftercare, or a lack thereof, may have a significant
effect on AVF patency.
Timing of first cannulation. Brescia and Cimino can-
nulated their pioneering AVF the first day after creation;
however, current practice allows for a maturation period
during which the draining vein will dilate and “arterialize”
or hypertrophy to create a durable conduit that will tolerate
repeated cannulation more readily.
The timing of the first needling can vary greatly be-
tween units and will often take into account urgency of
dialysis. Data from the Dialysis Outcomes and Practice
Patterns Study (DOPPS) suggests that first cannulation
⬍14 days after AVF formation is associated with a 2.1-fold
increase in the likelihood of AVF failure.49 Current consen-
sus is that cannulation ⬍14 days should be avoided,
whereas a minimum of 28 days should be allowed for AVF
maturation, the extent of which could then be assessed by
blood flow and diameter measurement in the draining
vein.27
Needling technique. Several techniques, including
rope ladder (RL), area puncture (AP), and buttonhole
(BH) formation can be used for needling the AVF, but little
data are reported regarding technique in relation to AVF
patency. The largest prospective comparison of different
needling techniques (BH and RL) suggested that BH
patients may have more unsuccessful cannulations com-
pared with the RL method.50 The frequency of hematoma,
aneurysm formation, and need for angioplasty was less in
BH patients, but the incidence of infection was higher.
Because this was a comparison of two different techniques
in two different units, bias due to other factors (expertise,
infection control methods, etc) is difficult to exclude, and

854 Smith et al
randomized data would be useful to confirm findings.
Reduced complications could be expected to improve pa-
tency, but these specific data are not available at present.
Area puncture is little researched but is generally the least-
favored technique.27
Surveillance. Thrombosis causing AVF failure is usu-
ally preceded by development of an underlying stenosis.
Consequently, the detection of stenosis in AVFs before
thrombosis could offer a strategy to improve AVF survival
by early intervention. Autologous AVF surveillance re-
search has concentrated on the use of DUS imaging, mea-
sures of access flow, and assessment of blood recirculation.
Fistula thrombosis was previously attributed to the pres-
ence of venous stenosis, and intra-access pressure ratios
(which will rise in the setting of venous stenosis) were thus
proposed to survey access function. However, fistula dys-
function or thrombosis may be due to inflow abnormalities
in 40% of cases.51 Intra-access pressure monitoring may not
alter with inflow restriction, whereas flow measures will
detect inflow or outflow dysfunction, or both, and are thus
the current preferred method of surveillance. Surveillance
programs with regular measures of flow are designed to
detect trends over time, which may indicate progressive
stenosis at a subclinical level and instigate proactive referral
for further imaging and intervention.
Conclusions of randomized trials of AVF surveillance
are varied. Several have reported fewer thrombosed AVFs
and superior primary patency with surveillance. However,
secondary or cumulative patency was not improved by
surveillance, although an increased incidence of angiogra-
phy and angioplasty has been reported. Two recent meta-
analyses scrutinized available randomized evidence and
concluded that access blood flow monitoring may prevent
thrombosis but may not reduce the risk of access loss.52,53
Large randomized multicenter trials reporting thrombosis
rate, access loss rate, central venous catheter use, hospital-
ization or intervention rates and costs between treatment
groups are needed to definitively determine which, if any,
surveillance method should be used and the usefulness of
proactive intervention protocols.
CONCLUSIONS
Many factors that may interact to determine the success
or failure of any individual AVF, and only those for which
evidence is available in current literature are discussed in
this review and summarized in Tables II and III. These and
many more factors may need to be considered when select-
ing access sites or vessels, surgical technique, adjuvant
treatments and follow up for AVF formation.
AUTHOR CONTRIBUTIONS
Conception and design: GS, IC
Analysis and interpretation: GS
Data collection: GS, RG
Writing the article: GS
Critical revision of the article: GS, RG, IC
Final approval of the article: GS, RG, IC
Statistical analysis: GS
JOURNAL OF VASCULAR SURGERY
March 2012
Obtained funding: Not applicable
Overall responsibility: GS
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Submitted Jun 1, 2011, accepted Jul 30, 2011.