Relationships Between Clinical Processes and Arteriovenous Fistula Cannulation and Maturation: A Multicenter Prospective Cohort Study

Michael Allon, Peter B. Imrey, Alfred K. Cheung, Milena Radeva, Charles E. Alpers, Gerald J. Beck, Laura M. Dember, Alik Farber, Tom Greene, Jonathan Himmelfarb, Thomas S. Huber, James S. Kaufman, John W. Kusek, Prabir Roy-Chaudhury, Michelle L. Robbin, Miguel A. Vazquez, Harold I. Feldman

Research output: Contribution to journalArticlepeer-review

49 Scopus citations


Background: Half of surgically created arteriovenous fistulas (AVFs) require additional intervention to effectively support hemodialysis. Postoperative care and complications may affect clinical maturation. Study Design: Hemodialysis Fistula Maturation (HFM) Study, a 7-center prospective cohort study. Setting & Participants: 491 patients with single-stage AVFs who had neither thrombosis nor AVF intervention before a 6-week postoperative ultrasonographic examination and who required maintenance hemodialysis. Predictors: Postoperative care processes and complications. Outcomes: Attempted cannulation, successful cannulation, and unassisted and overall clinical maturation as defined by the HFM Study criteria. Results: AVF cannulation was attempted in 443 of 491 (90.2%) participants and was eventually successful in 430 of these 443 (97.1%) participants. 263 of these 430 (61.2%) reached unassisted and 118 (27.4%) reached assisted AVF maturation (overall maturation, 381/430 [88.6%]). Attempted cannulation was less likely in patients of surgeons with policies for routine 2-week versus later-than-2-week first postoperative visits (OR, 0.21; 95% CI, 0.06-0.70), routine second postoperative follow-up visits (OR, 0.39; 95% CI, 0.15-0.97), and a routine clinical postoperative ultrasound (OR, 0.28; 95% CI, 0.14-0.55). Attempted cannulation was also less likely among patients undergoing procedures to assist maturation (OR, 0.51; 95% CI, 0.27-0.98). Unassisted maturation was more likely for patients treated in facilities with access coordinators (OR, 1.91; 95% CI, 1.17-3.12), but less likely after precannulation nonstudy ultrasounds (OR per ultrasound, 0.42 [95% CI, 0.26-0.68]) and initial unsuccessful cannulation attempts (OR per each additional attempt, 0.90 [95% CI, 0.83-0.98]). Overall maturation was less likely with infiltration before successful cannulation (OR, 0.44; 95% CI, 0.22-0.89). Among participants receiving maintenance hemodialysis before AVF surgery, unassisted and overall maturation were less likely with longer intervals from surgery to initial cannulation (ORs for each additional month of 0.81 [95% CI, 0.76-0.88] and 0.93 [95% CI, 0.89-0.98], respectively) and from initial to successful cannulation (ORs for each additional week of 0.87 [95% CI, 0.81-0.94] and 0.88 [95% CI, 0.83-0.94], respectively). Limitations: Surgeons’ management policies were assessed only by questionnaire at study onset. Most participants received upper-arm AVFs, planned 2-stage AVFs were excluded, and maturation time windows were imposed. Some care processes may have been missed and the observational design limits causal attribution. Conclusions: Multiple processes of care and complications are associated with AVF maturation outcomes.

Original languageEnglish (US)
Pages (from-to)677-689
Number of pages13
JournalAmerican Journal of Kidney Diseases
Issue number5
StatePublished - May 1 2018


  • Vascular access
  • arteriovenous access
  • arteriovenous fistula (AVF)
  • cannulation
  • end-stage renal disease
  • fistula maturation
  • hemodialysis
  • patency
  • process-of-care

ASJC Scopus subject areas

  • Nephrology


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