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J Am Soc Nephrol. 2018 Mar;29(3):1030-1040. doi: 10.1681/ASN.2017050559. Epub 2018 Jan 2.

Fibrotic Venous Remodeling and Nonmaturation of Arteriovenous Fistulas.

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DeWitt Daughtry Family Department of Surgery and.
Division of Nephrology and Hypertension, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida.
Division of Nephrology and Hypertension, Albany Medical College, Albany, New York.
Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah.
Medical Service, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah.
Department of Nephrology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China.
Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama; and.
DeWitt Daughtry Family Department of Surgery and


The frequency of primary failure in arteriovenous fistulas (AVFs) remains unacceptably high. This lack of improvement is due in part to a poor understanding of the pathobiology underlying AVF nonmaturation. This observational study quantified the progression of three vascular features, medial fibrosis, intimal hyperplasia (IH), and collagen fiber organization, during early AVF remodeling and evaluated the associations thereof with AVF nonmaturation. We obtained venous samples from patients undergoing two-stage upper-arm AVF surgeries at a single center, including intraoperative veins at the first-stage access creation surgery and AVFs at the second-stage transposition procedure. Paired venous samples from both stages were used to evaluate change in these vascular features after anastomosis. Anatomic nonmaturation (AVF diameter never ≥6 mm) occurred in 39 of 161 (24%) patients. Neither preexisting fibrosis nor IH predicted AVF outcomes. Postoperative medial fibrosis associated with nonmaturation (odds ratio [OR], 1.55; 95% confidence interval [95% CI], 1.05 to 2.30; P=0.03, per 10% absolute increase in fibrosis), whereas postoperative IH only associated with failure in those individuals with medial fibrosis over the population's median value (OR, 2.63; 95% CI, 1.07 to 6.46; P=0.04, per increase of 1 in the intima/media ratio). Analysis of postoperative medial collagen organization revealed that circumferential alignment of fibers around the lumen associated with AVF nonmaturation (OR, 1.38; 95% CI, 1.03 to 1.84; P=0.03, per 10° increase in angle). This study demonstrates that excessive fibrotic remodeling of the vein after AVF creation is an important risk factor for nonmaturation and that high medial fibrosis determines the stenotic potential of IH.


arteriovenous fistula; fibrosis; vascular access

[Available on 2019-03-01]

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