CLINICAL EPIDEMIOLOGY www.jasn.

org

Complications of the Arteriovenous Fistula: A

Systematic Review
Ahmed A. Al-Jaishi,*† Aiden R. Liu,*‡ Charmaine E. Lok,§ Joyce C. Zhang,*‡ and
Louise M. Moist*‡
*The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada;
†
Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada; ‡Department
of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; and §Department
of Medicine, Toronto General Hospital, Toronto, Ontario, Canada

ABSTRACT
The implementation of patient-centered care requires an individualized approach to hemodialysis vascular
access, on the basis of each patient’s unique balance of risks and benefits. This systematic review aimed to
summarize current literature on fistula risks, including rates of complications, to assist with patient-
centered decision making. We searched Medline from 2000 to 2014 for English-language studies with
prospectively captured data on $100 fistulas. We assessed study quality and extracted data on study
design, patient characteristics, and outcomes. After screening 2292 citations, 43 articles met our inclusion
criteria (61 unique cohorts; n.11,374 fistulas). Median complication rates per 1000 patient days were as
follows: 0.04 aneurysms (14 unique cohorts; n=1827 fistulas), 0.11 infections (16 cohorts; n.6439 fistulas),
0.05 steal events (15 cohorts; n.2543 fistulas), 0.24 thrombotic events (26 cohorts; n=4232 fistulas), and

CLINICAL EPIDEMIOLOGY
0.03 venous hypertensive events (1 cohort; n=350 fistulas). Risk of bias was high in many studies and event
rates were variable, thus we could not present pooled results. Studies generally did not report variables
associated with fistula complications, patient comorbidities, vessel characteristics, surgeon experience, or
nursing cannulation skill. Overall, we found marked variability in complication rates, partly due to poor
quality studies, significant heterogeneity of study populations, and inconsistent definitions. There is an
urgent need to standardize reporting of methods and definitions of vascular access complications in future
clinical studies to better inform patient and provider decision making.

J Am Soc Nephrol 28: 1839–1850, 2017. doi: https://doi.org/10.1681/ASN.2016040412

Current literature suggests the arteriovenous fistula
(fistula) to be the preferred type of vascular access
for hemodialysis.1–3 Once established, fistulas have
longer patency and lower rates of complications
compared with arteriovenous grafts and cathe-
ters.4,5 However, with the increasing proportion
of elderly and frail patients on hemodialysis, the
rate of failure to mature has increased with a de-
crease in patency rates. 6 The current focus on
patient-centered care requires individualized ap-
proaches to therapy, including the choice and use
of vascular access, on the basis of each patient’s
unique balance of risks and benefits. As such, com-
plications related to vascular access also deserve
careful consideration when individualizing the
choice of vascular access type, facilitating informed
consent, and providing an appropriate implemen-
tation plan (creation, monitoring, and use).
Fistula complications are associated with mor-
bidity, mortality, and a high economic burden.7–10
Although there have been systematic reviews and
meta-analyses on fistula patency and failure to
Received April 8, 2016. Accepted November 25, 2016.
Published online ahead of print. Publication date available at
www.jasn.org.
Correspondence: Prof. Louise Moist, Schulich School of Medi-
cine, Western University, The Lilibeth Caberto Kidney Clinical
Research Unit London Health Sciences Centre, Victoria Hospital,
800 Commissioners Rd, Room A2-338, E. London, ON N6A 5W9,
Canada. Email: louise.moist@lhsc.on.ca
Copyright © 2017 by the American Society of Nephrology

J Am Soc Nephrol 28: 1839–1850, 2017 ISSN : 1046-6673/2806-1839 1839

 CLINICAL EPIDEMIOLOGY www.jasn.org
mature, to our knowledge, no published systematic review has
evaluated fistula complication rates related to aneurysm, infec-
tion, ischemic steal syndrome, thrombosis, and venous hyper-
tension. We conducted this systematic review to concisely
summarize contemporary published information between 2000
and 2014 on the rates for the above-mentioned complications, as
well as to identify knowledge gaps in the existing literature.
RESULTS
The literature search yielded 2292 citations. All citations were
screened by title and abstract, resulting in 172 articles reviewed
in full-text. Thirty-five articles met eligibility criteria. Details of
the study selection are shown in Supplemental Figure 1. Twelve
additional studies were identified through manual search of
bibliographies of selected articles and eight were included in
our analyses. Thus, 43 studies (61 unique cohorts; n.11,374
fistulas—not all studies reported number of fistulas included)
were included from 19 countries. Most published studies were
from the United States (13 studies), Canada (five studies), and
Italy (four studies). One study reported outcomes of interest
across European countries and another reported on infections
internationally.11,12 All studies were published between 2001
and 2014 with patient recruitment beginning between 1986
and 2012. The characteristics of each study are described in
Table 1.
Patient Population
Patient demographic data, comorbid conditions, and site of
fistula creation were not always reported. Three out of the 39
observational studies were prospective surveillance studies and
generally did not report baseline characteristics specific to pa-
tients using a fistula. However, when the data were reported, the
median age was 61 years (ranging from 46 to 85 years;
interquartile range [IQR] =7.6 years). The median proportion
of men and patients with diabetes was 59% (range 27%–81%;
IQR=13%) and 37% (range 8%–71%; IQR=20%), respec-
tively. The median proportion of patients who had an upper
arm fistula was 44% (range 0%–100%; IQR=70%). A sum-
mary of characteristics is presented in Table 2.
Study Quality Assessment
Methods were inadequately reported and definitions were in-
consistent across studies. Definitions were not reported for five
of nine studies reporting aneurysm, seven of 23 studies report-
ing infections, nine of 12 studies reporting ischemic steal syn-
drome, 13 of 18 studies reporting thrombosis, and the one
study reporting venous hypertension. Loss to follow-up was
not reported in 28 out of 38 observational studies and one of the
four randomized controlled trials. However, when reported,
the median loss to follow-up was ,10% for all studies. For
observational studies, 38 of 39 studies were at moderate or
high risk of bias in at least one domain. For randomized trials,
three of four studies were at moderate or high risk of bias in at
1840 Journal of the American Society of Nephrology
least one domain. The distribution of the components that
described study quality is summarized in Supplemental Tables
2 and 3.
Incidence of Primary Outcomes
All complication rates reported by study are presented in Sup-
plemental Table 4. Below we report summary statistics. When
$2 event rates were reported for a specific subgroup, we cal-
culated the median event rate for subgroups of nonelderly and
elderly patients, lower and upper arm fistulas, as well as but-
tonhole and rope ladder cannulation (Supplemental Table 5).
Aneurysm
The median rate of aneurysm was 0.04 events per 1000 patient
days (ranging from 0 to 3.01; IQR=0.06) among 14 unique co-
horts (n=1827 fistulas; Supplemental Figure 2). Van Loon et al.13
reported the highest rate of aneurysm (3.01 per 1000 patient
days) among patients using rope ladder cannulation. The next
highest rate was reported by the same study for buttonhole can-
nulation at a rate of 0.13 events per 1000 patient days.13
Infection
Twenty-three studies reported the incident rate of infection for
28 unique cohorts. The median rate of total infections was 0.11
infections per 1000 patient days (range 0–0.98; IQR=0.29)
among 16 unique cohorts (n.6439 fistulas; Figure 1). How-
ever, Ravani et al. reported an event rate of 3, 1.7, and 0.9
infections per 1000 patient days in the first 1–3, 3–6, and
6–12 months of starting dialysis, respectively. Only the latter
event rate was entered in the overall median rate.
The median rate for bloodstream infection was 0.05 events
per 1000 patient days (range 0–0.55; IQR=0.08) among 9 co-
horts (n.753 fistulas; Supplemental Figure 3). The median
rate for vascular access site infections was 0.03 events per 1000
patient days (range 0–0.26; IQR=0.05) among 14 unique co-
horts (n.771 fistulas; Supplemental Figure 4). Using button-
hole cannulation, the median rate of infection was 0.17 (two
studies; N fistulas=302) compared with 0.001 (two studies;
N fistulas=527) events per 1000 patient days for rope ladder
cannulation.
Ischemic Steal Syndrome
Eleven studies reported event rates of ischemic steal syndrome for
15 unique cohorts (n.2543; Figure 2). The median incident rate
of ischemic steal syndrome was 0.05 events per 1000 patient days
(range 0–0.27; IQR=0.04). The highest rates were 0.18 and 0.27
events per 1000 patient days reported for elderly patients ($80
years) and those with an upper arm fistula, respectively.
Thrombosis
Fifteen studies reported event rates of thrombosis in 26 unique
cohorts (n=4232 fistulas; Figure 3). The median thrombosis
rate was 0.24 events per 1000 patient days (range 0.07–0.71;
IQR=0.25). Patients undergoing vascular access surveillance
(e.g., Qa surveillance) had a median thrombosis rate of 0.33
J Am Soc Nephrol 28: 1839–1850, 2017
 Table 1. Study characteristics
Author (Yr Recruitment Type Cohort Follow- No. of Upper First
Country Age, yr Men, % DM, % CAD, % CHD, %
Published) Start of Study Subset Up (Mo) Fistulas Arm, % Fistula, %
McCarley et al. United States 1996 Retrospective NM 11.0 39 . . 55.3 51 36 . .
(2001)58a,b
McCarley et al. United States 1996 Retrospective DVPM 12.0 41 . . 56.6 54 36 . .
(2001)58a,b
McCarley et al. United States 1997 Retrospective VABFM 10.0 43 . . 56.1 59 34 . .
(2001)58a,b
Tokars et al. United States 1997 Prospective Standard 5.2 . . . . . . . .
(2001)59

J Am Soc Nephrol 28: 1839–1850, 2017

Dixon et al. United States 1992 Retrospective Lower arm . 88 0 . 50.9 81 47 39 .
(2002)60
Dixon et al. United States 1992 Retrospective Upper arm . 117 100 . 57.8 56 56 49 .
(2002)60
Ravani et al. Italy 1995 Prospective Standard 20.4 197 19 100 65.7 59 22 . 14
(2002)61
Saxena et al. Saudi Arabia 1996 Prospective Diabetic nasal 36.0 . . . . . . . .
(2002)62 carriers of
MRSA/MSSA
Saxena et al. Saudi Arabia 1996 Prospective Nondiabetic nasal 36.0 . . . . . . . .
(2002)62 carriers of
MRSA/MSSA
Stevenson et al. United States 1998 Retrospective Standard . . . . . . . . .
(2002)63
Taylor et al. Canada 1998 Surveillance Standard 6.0 . . . . . . . .
(2002)64
Tokars et al. United States 1999 Prospective Standard . . . . . . . . .
(2002)65
Elseviers et al. Europe 1998 Prospective Standard 12.0 1049 . . . 56 . . .
(2003)11b
Lok et al. (2003)66a Canada 1997 Prospective Duplex US 9.2 189 30 96 57.5 71 . . .
Monitoring
Lok et al. (2003)66a Canada 1999 Prospective Transonic 10.4 241 30 96 57.5 71 . . .
surveillance
www.jasn.org

Saxena et al. Saudi Arabia 1997 Surveillance Standard . . . . 47.5 54 . . .

(2003)67b
Bonforte et al. Italy 1991 Prospective Lower arm 27.0 112 0 . 71 50 22 . .
(2004)68
Astor et al. United States 1995 Prospective Standard 35.9 185 . . 56.8 71 47 42 .
(2005)69

Arteriovenous Fistula Complications: A Systematic Review

Gilad et al. Israel 2002 Surveillance Standard . . . . 63.5 55 48 44 21
(2005)70b
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 Table 1. Continued

1842
Author (Yr Recruitment Type Cohort Follow- No. of Upper First
Country Age, yr Men, % DM, % CAD, % CHD, %
Published) Start of Study Subset Up (Mo) Fistulas Arm, % Fistula, %
Lok et al. (2005)71 Canada 1995 Retrospective Nonelderly (,65 65.0 248 44 100 46 65 29 24 15
yr)
Lok et al. (2005)71 Canada 1995 Retrospective Elderly ($65 yr) 51.7 196 53 100 74 69 30 44 29
Mallamaci et al. Italy . Prospective Standard 32.5 205 5 . 59.4 57 14 . .
(2005)72
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Shahin et al. United States 1992 Retrospective Standard 21.0 146 51 100 54.9 58 49 53 .
(2005)73
Shahin et al. United States 1999 Retrospective Qa surveillance 19.0 76 61 100 57.6 59 57 68 .
(2005)73
Jennings et al. United States 2003 Retrospective Standard 11.0 134 91 74 61 54 52 . .
(2006)74
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Polkinghorne et al. Australia 2001 RCT Standard 16.2 68 34 . 56.4 71 28 29 .

(2006)75

Journal of the American Society of Nephrology

Polkinghorne et al. Australia 2001 RCT Qa surveillance 17.3 69 36 . 60 65 35 28 .
(2006)75
Roozbeh et al. Iran . Prospective Standard 23.0 171 57 . 53 68 27 . .
(2006)76a
Huijbregts et al. The Netherlands 2004 Prospective Standard 8.6 285 40 . 64.6 62 33 23 .
(2008)5
Pflederer et al. United States 2004 Retrospective Standard 8.0 321 37 . 64.5 65 43 . .
(2008)77
Pflederer et al. United States 2004 Retrospective AVF-T 8.0 161 100 . 63.3 61 45 . .
(2008)77
Qasaimeh et al. Jordan 2004 Retrospective Standard 12.0 104 . . . 52 32 . .
(2008)78b
Tessitore et al. Italy 2002 Prospective Standard 31.0 97 18 . 65.1 64 19 62 .
(2008)79c
Tessitore et al. Italy 2002 Prospective Qa Surveillance 30.0 62 21 . 63.4 52 31 69 .
(2008)79c
Koksoy et al. Turkey 2003 RCT AVF-T 43.6 50 100 0 54.66 52 32 . .
(2009)80
Koksoy et al. Turkey 2003 RCT Upper arm 39.5 50 100 0 54.78 60 24 . .
(2009)80
Papanikolaou Greece 1986 Retrospective Lower arm . . 100 . . 45 8 . .
et al. (2009)81
Papanikolaou Greece 1986 Retrospective Upper arm . . . . . 45 8 . .
et al. (2009)81
Korkut et al. Turkey 2004 Retrospective AVF-T 48.0 350 100 . 57.8 44 51 15 .
(2010)15
Paul et al. (2010)82 United States 2006 Retrospective Endo/AVF-T 14.0 98 100 47 60 40 49 . .
Paul et al. (2010)82 United States 2006 Retrospective Open/AVF-T 18.0 78 100 41 62 27 56 . .

J Am Soc Nephrol 28: 1839–1850, 2017

 Table 1. Continued

Author (Yr Recruitment Type Cohort Follow- No. of Upper First

Country Age, yr Men, % DM, % CAD, % CHD, %
Published) Start of Study Subset Up (Mo) Fistulas Arm, % Fistula, %
van Loon et al. The Netherlands 2007 Prospective Rope ladder . 70 39 84 65 67 21 80 .
(2010)13
van Loon et al. The Netherlands 2007 Prospective Buttonhole . 75 51 68 67 59 27 61 .
(2010)13
Jennings et al. United States 2003 Retrospective Elderly ($65 yr) 17.0 461 38 77 73 49 60 . .
(2011)83a
Labriola et al. Belgium 2001 Retrospective Standard 35.1 . 37 . 70.4 66 33 . .

J Am Soc Nephrol 28: 1839–1850, 2017

(2011)84
Ng et al. (2011)85 United States 1996 Prospective Standard 6.0 476 . . 61.1 73 49 47 34
Ayez et al. (2012)86 The Netherlands 2000 Retrospective Upper arm 19.0 173 100 68 62.61 52 46 3 57
Renaud et al. Singapore 2008 Retrospective Nonelderly (,65 12.0 191 41 100 52 60 70 41 .
(2012)87 yr)
Renaud et al. Singapore 2008 Retrospective Elderly ($65 yr) 13.0 89 39 100 72 55 71 49 .
(2012)87
Kandil et al. United Kingdom 2007 Retrospective Buttonhole . 227 . . 63.8 61 46 . .
(2013)88
Lin et al. (2013)14 Taiwan 2008 RCT Infrared 12.0 60 15 100 63.2 53 47 17 .
Lin et al. (2013)14 Taiwan 2008 RCT Standard 12.0 62 18 100 63 57 37 12 .
Macrae et al. Canada 2006 RCT Buttonhole . 70 84 83 77.2 73 49 61 .
(2013)19
Macrae et al. Canada 2006 RCT Standard . 69 75 86 66.1 67 54 42 .
(2013)19
Ravani et al. International 1996 RCT Standard . 3352 . 100 62.2 68 38 36 29
(2013)12
de Albuquerque Brazil 2010 Surveillance Standard . . . . . . . . .
et al. (2013)89
Agarwal et al. United States 2005 Retrospective AVF-T (1-stage) . 61 100 . 59.1 . . . .
(2014)90
Agarwal et al. United States 2005 Retrospective AVF-T (2-stage) . 83 100 . 61.5 . . . .
(2014)90
Badawy et al. Kuwait 2012 Surveillance Standard . . . . 58.1 40 . . .
www.jasn.org

(2014)91b
Lok et al. (2014)92 Canada 2000 Retrospective Rope ladder 29.6 457 . . 58.8 58 36 29 16
Olsha et al. Turkey 2005 Retrospective Elderly ($80 yr) 17.6 128 71 . 85 66 40 45 24
(2014)93
DM, diabetes mellitus; CAD, coronary artery disease; CHD, Congestive Heart Disease; NM, no monitoring; ., data not reported; DVPM, dynamic venous pressure monitoring; VABFM, vascular access blood flow
monitoring; standard, all fistula locations; lower arm, a cohort consisting of patients only fistulas located in the lower arm; upper arm, patients with fistulas located in the upper arm, including transposed bra-
chiobasilic fistulas; MRSA, methicillin‐resistant Staphylococcus aureus; MSSA, methicillin‐sensitive Staphylococcus aureus; duplex US, duplex ultrasound; RCT, randomized controlled trial; AVF-T, transposed

Arteriovenous Fistula Complications: A Systematic Review

arteriovenous fifistula; endo/AVF-T, a transposed arteriovenous fistula created using an endoscopic procedure; open/AVF-T, a transposed arteriovenous fistula created using a long open incision technique; rope
ladder, rope ladder cannulation; buttonhole, buttonhole cannulation.
a
Percentage of patients whose diabetes was the cause of kidney failure.
b
Baseline data reported for fistulas and other accesses grouped together.
c
CLINICAL EPIDEMIOLOGY

CAD was defined as presence of cardiovascular disease.

1843
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Table 2. Summary of study characteristics (61 cohorts in total) Incidence of Secondary Outcomes
Variable N (%) Median Min Q1 Q3 Max Endovascular interventions (34 unique
Proportion of patients with first fistula, % 23 (38) 96 0 68 100 100 cohorts; n=3930) and surgical (27 unique
Mean age reported in study, yr 50 (82) 61.05 46 56.8 64.6 85 cohorts; n=2886) revisions were the most
Time from fistula creation to use, mo 15 (25) 3.49 1.11 1.73 4.87 5.92 commonly reported secondary outcomes.
Body mass index, kg/m2 15 (25) 25.5 23.39 24.9 26.8 28 Endovascular interventions included angio-
Coronary artery disease, % 27 (44) 42 3 28 53 80 plasty (with or without thrombectomy),
Congestive heart disease, % 9 (15) 24 14 16 29 57 stenting, and mechanical thrombolysis. The
Diabetes, % 47 (77) 37 8 29 49 71 median event rates were 0.82 (range 0–7.42;
Men, % 52 (85) 59 27 53 66 81 IQR=1.39) and 0.19 (range 0–0.77;
Peripheral vascular disease, % 22 (36) 16 0 9 23 53
IQR=0.15) per 1000 patient days for endovas-
Patients with a fistula, % 59 (97) 100 38 100 100 100
cular interventions and surgical revisions, re-
White, % 23 (38) 74 44 63 90 100
Upper arm, % 41 (67) 44 0 30 100 100
spectively. All-cause mortality (13 unique
There were 61 cohorts in total. N, total number of cohorts that reported the variable of interest; Min/
cohorts; n=1880 fistulas), bleeding (seven
Max, minimum/maximum reported value; Q1 and Q3, the values which 25% and 75% of the data set lie unique cohorts; n.1672 fistulas), and total
below, respectively. fistula complications (six unique cohorts;
n.1666) were reported at a median rate of
events per 1000 patient days (seven groups; 721 fistulas). Lin 0.33 (range 0.09–0.64; IQR=0.11), 0.06 (range 0.02–0.11;
et al.14 reported 1.43 thrombotic events per 1000 patient days IQR=0.05), and 0.56 (range 0.13–1.56; IQR=0.79) per 1000
rate at 3 months compared with 0.49 events per 1000 patient patient days, respectively. Other outcomes such as catheter
days at 12 months (only the event rate at 12 months was in- insertions, fistula ligation due to high cardiac output, difficult
cluded in the median calculation above). A number of studies cannulations, hematomas, and hospitalizations were infrequently
included prevalent patients and thus did not report throm- reported (Supplemental Table 4). No study reported on pulmo-
botic events occurring before or shortly after starting dialysis. nary hypertension or heart failure.

Venous Hypertension
Only one study reported an event rate of 0.03 venous hyper-
tensive events per 1000 patient days. However, it should be
noted that arm edema was included as an event. This cohort
consisted of incident patients (n=350 fistulas) with transposed
upper arm fistulas with a mean age of 58 years.15
DISCUSSION
Our review identified 61 unique cohorts that reported on the
fistula event rate of aneurysms, infections, steal syndrome,
thrombosis, venous hypertension, and our secondary

Figure 1. Studies reporting the incident rate for all types of infections per 1000 patient days. Dashed line refers to the median event rate
per 1000 patient days. AVF-T, transposed arteriovenous fistula; buttonhole, all patients cannulated using a buttonhole technique;
elderly, $65 years; rope ladder, all patients cannulated using a rope ladder technique; standard, no specific cohort followed.

1844 Journal of the American Society of Nephrology J Am Soc Nephrol 28: 1839–1850, 2017
 www.jasn.org CLINICAL EPIDEMIOLOGY

Figure 2. Studies reporting the incident rate for ischemic steal syndrome per 1000 patient days. Dashed line refers to the median event rate per
1000 patient days. AVF-T, transposed arteriovenous fistula; elderly, $65 years unless otherwise specified; endo AVF-T, fistula transposition of a
deep vein through endoscopic procedure; lower arm, cohort made up of all lower arm fistulas; open AVF-T, fistula transposition of a deep vein
through a long open incision; standard, no specific cohort followed; upper arm, cohort made up of all upper arm fistulas.

outcomes among patients using a fistula. We identified three
important findings: (1) the contemporary rates of complica-
tions in fistulae; (2) the critical need for standardized defini-
tions to report complication rates in order to allow proper
evaluation of these outcomes across studies; and (3) a clear
need to improve reporting and data quality of observational
data in the area of vascular access.
Despite the burden of vascular access complications on
patients and the healthcare system, there remains a poor con-
sensus on the incidence risk and factors associated with

Figure 3. Studies reporting the incident rate for thrombosis per 1000 patient days. Dashed line refers to the median event rate per 1000 patient
days. AVF-T, transposed arteriovenous fistula; buttonhole, all patients cannulated using a buttonhole technique; DUS monitoring, duplex ul-
trasound monitoring of blood flow; DVPM, dynamic venous pressure monitoring; elderly, $65 years unless otherwise specified; infrared,
patients received far infrared therapy 3 times weekly for a year; lower arm, cohort made up of all lower arm fistulas; NM, no monitoring
(standard care); Qa surveillance, access blood flow monitoring; standard, no specific cohort followed; TUS surveillance, transonic ultrasound
monitoring of blood flow; upper arm, cohort made up of all upper arm fistulas; VABFM, vascular access blood flow monitoring.

J Am Soc Nephrol 28: 1839–1850, 2017 Arteriovenous Fistula Complications: A Systematic Review 1845
 CLINICAL EPIDEMIOLOGY www.jasn.org
increased rates of fistula complications. The wide variation in
complication event rates across studies is attributed to variation
in definitions, inconsistent reporting, and differences in patient
populations.
With regard to fistula aneurysmal complications, repeated
punctures in a clustered area can weaken the vascular access
wall and cause aneurysm formation. Aneurysmal dilatation
can occur naturally over time because of the higher blood
flow and the process may be accelerated by raising the pressure
within the fistula. A previous review documented an aneurysm
rate between 5% and 6% (no units were provided), a much
higher rate than our median rate of 1.5% per year (0.04 per
1000 patient days).16 Aneurysms generally require surgical re-
pair if there is evidence of loss of skin integrity or ulceration.
Left untreated, aneurysms are at risk of rupture and serious
hemorrhage, as well as limiting the available sites for cannu-
lation. If inadvertently traumatized, the aneurysm may rup-
ture which can be fatal due to exsanguination.17,18
The clinical practice guidelines for the National Kidney
Foundation Kidney Disease Outcomes Quality Initiative
(NKF/KDOQI) and the Canadian Society of Nephrology
(CSN) recommend that the infection rate should not exceed
0.01 events per patient year (0.027 per 1000 patient days).1,2 On
the basis of the evidence from the current literature, the rate of
infection was higher for 23 out of 30 cohorts compared with
recommended rates proposed by practice guidelines. We also
found that patients cannulated using the buttonhole tech-
nique had a much higher rate of infection compared with
rope ladder cannulation. Similar results were found in a recent
randomized controlled trial that found 17% of patients had an
infection when using buttonhole compared with 0% using the
rope ladder technique.19 Compared with catheters and arte-
riovenous (AV) grafts, fistulas have lower rates of infection.
Previous studies have shown that the rate of catheter infection
ranges from 5% to 18% per patient year but this depends on
the duration of catheter use.20,21 Similarly, AV-grafts may be
at a higher risk for infections.2,22 The rate of local and bacter-
emic infections for AV-grafts can range between 11% and 20%
per patient year.23–26
Ischemic steal syndrome is another important complication
of fistulas with significant patient implications including pain
and loss of access or extremity function. The NKF/KDOQI and
CSN have made no recommendations for target rates of ische-
mic steal syndrome. Previous studies have reported symptom-
atic ischemic steal occurrence to range between 1% and 2% for
lower arm fistulas and between 5% and 10% among patients
using an upper arm fistula.27–32 Indeed, we found that as the
proportion of upper arm fistulas increased, the rate of ische-
mic steal syndrome increased. We found that the rate of ische-
mic steal syndrome was similar to estimates reported in the
NKF/KDOQI guidelines (1%–4% of patients) and other stud-
ies.2 Compared with AV-grafts, fistulas have a two-fold lower
risk of developing ischemic steal syndrome.2,22,33
Thrombosis is a common early and late fistula complication
that can lead to fistula loss. The current NKF/KDOQI and CSN
1846 Journal of the American Society of Nephrology
guidelines recommend that center-specific thrombosis rate for
the fistula should not exceed 0.25 events per patient year (0.69
per 1000 patient days).34 Among studies included in our re-
view, the thrombosis rates observed were generally lower (with
the exception of two studies) than the target rates recom-
mended by practice guidelines. Furthermore, the rates of
thrombosis observed in studies before 2000 were also compa-
rable to rates reported in our study.35,36 Compared with AV-
grafts, fistulas have lower rates of thrombotic events. Previous
reports have reported graft thrombosis to exceeded 0.8 events
per patient year (2.2 events per 1000 patient days).37–39
The most common cause of venous hypertension is central
stenosis secondary to placement of central venous catheters
and devices.40,41 Symptoms of venous hypertension include
finger and hand edema that may progress to limit upper ex-
tremity mobility. Beyond swelling, extremely advanced stages
of this complication can lead to hand and extremity discolor-
ation and even venous gangrene.42 This complication may be
under-reported and requires more attention in future studies
where they explicitly report its definition, diagnosis, and oc-
currence.
Studies included in our review varied substantially in qual-
ity, outcome definitions, and patient population. Accordingly,
the rate of fistula complications varied and may reflect selection
bias of study participants, differences in clinical practice, in-
consistent levels of vascular access care and monitoring across
facilities, and variable case definitions. Despite published rec-
ommendations for standardized vascular access reporting,43–45
the majority of studies failed to report definition of outcomes
and only a smaller number of studies used published standard-
ized definitions.
In this review, we do not report on fistula nonmaturation or
primary failure. We recently published a separate systematic
review and meta-analysis, indicating primary failure occurs in
approximately 23% (95% confidence interval [95% CI], 18%
to 28%) of created fistulas.6 We also found the primary patency
rate was 60% (95% CI, 56% to 64%) at 1 year and 51% (95%
CI, 44% to 58%) at 2 years. The secondary patency rate was
71% (95% CI, 64% to 78%) at 1 year and 64% (95% CI, 56%
to 73%) at 2 years.
Our review has a number of strengths compared with prior
narrative reviews on this topic. We conducted a comprehensive
search of the literature and systematically identified relevant
studies in accordance with published guidelines and a pub-
lished prespecified protocol. We prespecified a wide range of
primary and secondary outcomes that are relevant to pa-
tients, physicians, and administrators. To our knowledge,
this is the first review that has examined fistula complication
in the contemporary dialysis population. Previous narrative
reviews have included studies from the 1970s when patient
characteristics, clinical focus, and policies differed from the
current dialysis environment. Furthermore, previous re-
views reported the proportion of patients with an infection,
ischemic steal syndrome, and thrombosis events as opposed
to the event rate.46–49
J Am Soc Nephrol 28: 1839–1850, 2017

Our study does have limitations. Heterogeneity between
studies precluded precise estimates of complication incidence
rates and precluded the pooling of risk factors; it has been
suggested that pooling results when not warranted may lead
to misleading conclusions.50 We restricted this review to arti-
cles published in English; whether this introduced some bias is
controversial.51 We also did not query prospective databases
(e.g., Dialysis Outcomes and Practice Patterns Study, Centers
for Medicare & Medicaid Services, etc.) without peer-reviewed
published data. Finally, when calculating event rates, we
assumed a constant hazard ratio; however, it has been shown
that hazard ratios of fistula outcomes can vary over time, with
higher hazard rates being observed within the first 6 months of
dialysis.52
The quality of primary studies inherently limits the conclu-
sions that can be drawn from this review. We were also unable to
differentiate complications that occurred in fistulas that were
created in the predialysis period and a number of studies re-
ported outcomes for patients already on dialysis. Risk factors
for fistula complications which include patient comorbidities,
vessel characteristics, surgeons’ experience, and nursing expe-
rience with cannulation were generally not reported. Addi-
tionally, factors on timing between fistula creation and fistula
use, timing of vascular access interventions, and clinical mon-
itoring or surveillance practices were also not reported. These
variables may have explained some of the heterogeneity in the
literature. The paucity in reporting of risk factors impairs our
ability to identify patients at highest risk for complications.
We found that the rates of aneurysm, ischemic steal syn-
drome, and thrombosis rates were similar or less than previ-
ously published reports and those reported in NKF/KDOQI
guidelines (update 2006). However, the infection rate was
much higher than the range recommended by NKF/KDOQI
guidelines, although this varied by cannulation technique. We
found marked variability in complications rates in part due to
the poor quality of studies, significant heterogeneity of study
populations, and inconsistent definitions. This information on
complication rates is critical to informing patient-physician
decision making and patient consent, and guiding resource
allocation for vascular access care. Having accurate informa-
tion on fistula complications and patients at highest risk for
complications is important in making informed decisions and
choosing the appropriate vascular access on the basis of the
risks.
There is an urgent need to standardize reporting of meth-
ods, baseline patient and access characteristics, and complica-
tions of vascular access in future clinical studies.
CONCISE METHODS
We conducted and reported this systematic review according to pub-
lished guidelines (Preferred Reporting Items for Systematic Reviews
and Meta-Analyses [PRISMA] checklist: Supplemental Table 1)
using a prespecified protocol (CRD42014010444 and Supplemental
J Am Soc Nephrol 28: 1839–1850, 2017
www.jasn.org CLINICAL EPIDEMIOLOGY
Item 1).53,55 Description of studies eligible for review, data sources,
study selection, data abstraction, and quality assessment used for this
review have been reported elsewhere.6,55
Briefly, we included English-language studies indexed in Medline
that followed patients prospectively (observational cohort, random-
ized control trials, or surveillance programs) for a period of at least 3
months. Studies included were published between January 1, 2000 and
December 31, 2014 and reported on $100 fistulas. Two blinded in-
dependent reviewers (A.A.A. and one of A.R.L. or J.C.Z.) selected the
studies using a standardized form with a third reviewer adjudicating
discrepancies when necessary. We assessed risk of bias using previ-
ously reported methods and modified these tools as appropriate,56,57
and abstracted data on study methodology and cohort characteristics.
All studies must have reported on at least one of the primary out-
comes: (1) aneurysm, (2) infections, (3) ischemic steal syndrome, (4)
thrombosis, or (5) venous hypertension among hemodialysis patients
using a fistula. When reported, we also captured the following sec-
ondary outcomes: (1) difficult cannulation, (2) bleeding, (3) hema-
toma, (4) catheter insertion, (5) endovascular intervention, (6)
surgical revisions, (7) hospitalization (infection-related), (8) hospi-
talization (VA-related), (9) hospitalizations (all-cause), (10) pulmo-
nary hypertension, (11) high cardiac output, (12) heart failure, (13)
all-cause mortality, and (14) total complications.
Study Definitions
We used outcome definitions in accordance with the Society of Vas-
cular Surgery (SVS) and the American Association of Vascular Surgery
as well as the North American Vascular Access Consortium (NAVAC)
(below).43,44 The SVS and NAVAC did not report a definition for
aneurysm. When the study definition was not in accordance with
previously published definitions, we noted the differences in our
tables. Definitions for infections and venous hypertension were in-
tentionally kept broad to include all variations in the published
literature.
Primary Outcome Definitions
(1) Aneurysm: Diffuse and progressive degeneration of the vascular
access site. Patient has signs of bleeding, infection, or ulceration.16,45
(2) Infections: Definite or probable local vascular access infections,
vascular access–related sepsis, bacteremia, or a composite of these
infections. (3) Ischemic steal syndrome (SVS): One or more clinical
manifestations of: pain, ischemic neuropathy, ulceration, and gan-
grene felt to be related to a fistula diverting blood from the distal
circulation resulting in a zone of arterial insufficiency in the tissues
distal to the fistula.44 (4) Thrombosis (SVS and NAVAC): Absence of
bruit or thrill, using auscultation and palpation, throughout systole
and diastole at least 8 cm proximal to the arteriovenous anastomo-
sis.43,44 (5) Venous hypertension (SVS): High pressure in veins due to
damage to venous system often presenting with arm and hand swell-
ing; dusky, rubber color of the hand; and dilated veins on the arm
and/or chest wall.
Summary Statistics
We report the median and range for the event rate (per 1000 patient
days) of an outcome. Because of differences in sampled populations,
Arteriovenous Fistula Complications: A Systematic Review 1847
 CLINICAL EPIDEMIOLOGY www.jasn.org
outcome definitions, prevalence of comorbid conditions, and variable
sample selection criteria, it was not appropriate to calculate a sum-
mary statistic on the basis of the weighted average. When incidence
rates were not reported, we calculated the overall follow-up time (de-
nominator) by multiplying the mean follow-up time by the number of
patients. We used the overall follow-up time to calculate the event rate
per 1000 patient days. Using this method, we assumed that the hazard
rate of developing a particular outcome was constant across individ-
uals and over time.
ACKNOWLEDGMENTS
A.A.A. is supported by the Kidney Foundation of Canada Allied Health
Doctoral Fellowship.
DISCLOSURES
None.
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