Fibrotic venous remodeling and nonmaturation of arteriovenous fistulas

Laisel Martinez, Juan C. Duque, Marwan Tabbara, Angela Paez, Guillermo Selman, Diana R. Hernandez, Chad A. Sundberg, Jason Chieh Sheng Tey, Yan Ting Shiu, Alfred K. Cheung, Michael Allon, Omaida C Velazquez, Loay Salman, Roberto I Vazquez-Padron

Research output: Contribution to journalArticle

5 Citations (Scopus)

Abstract

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 infibrosis), 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.

Original languageEnglish (US)
Pages (from-to)1030-1040
Number of pages11
JournalJournal of the American Society of Nephrology
Volume29
Issue number3
DOIs
StatePublished - Mar 1 2018

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Arteriovenous Fistula
Tunica Intima
Fibrosis
Hyperplasia
Odds Ratio
Blood Vessels
Veins
Collagen
Confidence Intervals
Observational Studies
Arm

ASJC Scopus subject areas

  • Nephrology

Cite this

Fibrotic venous remodeling and nonmaturation of arteriovenous fistulas. / Martinez, Laisel; Duque, Juan C.; Tabbara, Marwan; Paez, Angela; Selman, Guillermo; Hernandez, Diana R.; Sundberg, Chad A.; Sheng Tey, Jason Chieh; Shiu, Yan Ting; Cheung, Alfred K.; Allon, Michael; Velazquez, Omaida C; Salman, Loay; Vazquez-Padron, Roberto I.

In: Journal of the American Society of Nephrology, Vol. 29, No. 3, 01.03.2018, p. 1030-1040.

Research output: Contribution to journalArticle

Martinez, L, Duque, JC, Tabbara, M, Paez, A, Selman, G, Hernandez, DR, Sundberg, CA, Sheng Tey, JC, Shiu, YT, Cheung, AK, Allon, M, Velazquez, OC, Salman, L & Vazquez-Padron, RI 2018, 'Fibrotic venous remodeling and nonmaturation of arteriovenous fistulas', Journal of the American Society of Nephrology, vol. 29, no. 3, pp. 1030-1040. https://doi.org/10.1681/ASN.2017050559
Martinez, Laisel ; Duque, Juan C. ; Tabbara, Marwan ; Paez, Angela ; Selman, Guillermo ; Hernandez, Diana R. ; Sundberg, Chad A. ; Sheng Tey, Jason Chieh ; Shiu, Yan Ting ; Cheung, Alfred K. ; Allon, Michael ; Velazquez, Omaida C ; Salman, Loay ; Vazquez-Padron, Roberto I. / Fibrotic venous remodeling and nonmaturation of arteriovenous fistulas. In: Journal of the American Society of Nephrology. 2018 ; Vol. 29, No. 3. pp. 1030-1040.
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abstract = "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 infibrosis), 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.",
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