Research ArticleVASCULAR SURGERY

Artery to vein configuration of arteriovenous fistula improves hemodynamics to increase maturation and patency

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Science Translational Medicine  19 Aug 2020:
Vol. 12, Issue 557, eaax7613
DOI: 10.1126/scitranslmed.aax7613

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Favorable fistulae

Patients with end-stage kidney disease require surgery to create arteriovenous fistulae (AVF) for dialysis access. Bai et al. investigated whether an artery-to-vein (A-V) configuration using radial artery deviation and reimplantation improved maturity and patency of AVF. They saw decreased hyperplasia and improved hemodynamics in A-V–configured AVF in rats and longer-term patency with reduced reintervention rates in patients. Results support the use of A-V–configured AVF for durable hemodialysis access.

Abstract

Arteriovenous fistulae (AVF) are the preferred mode of hemodialysis access, but 60% of conventional [vein-to-artery (V-A)] AVF fail to mature, and only 50% remain patent at 1 year. We previously showed improved maturation and patency in a pilot study of the radial artery deviation and reimplantation (RADAR) technique that uses an artery-to-vein (A-V) configuration. Here, we show that RADAR exhibits higher rates of maturation, as well as increased primary and secondary long-term patencies. RADAR is also protective in female patients, where it is associated with decreased reintervention rates and improved secondary patency. RADAR and conventional geometries were compared further in a rat bilateral carotid artery-internal jugular vein fistula model. There was decreased cell proliferation and neointimal hyperplasia in the A-V configuration in male and female animals, but no difference in hypoxia between the A-V and V-A configurations. Similar trends were seen in uremic male rats. The A-V configuration also associated with increased peak systolic velocity and expression of Kruppel-like factor 2 and phosphorylated endothelial nitric oxide synthase, consistent with improved hemodynamics. Computed tomography and ultrasound-informed computational modeling showed different hemodynamics in the A-V and V-A configurations, and improving the hemodynamics in the V-A configuration was protective against neointimal hyperplasia. These findings collectively demonstrate that RADAR is a durable surgical option for patients requiring radial-cephalic AVF for hemodialysis access.

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