Balloon-Assisted Maturation in Salvaging Stenosed Arteriovenous Fistulas: A Case Series and Clinical Insights

Abstract

Background An autogenous arteriovenous fistula (AVF), created by direct anastomosis of an adjacent artery and vein, is the preferred vascular access for maintenance hemodialysis in patients with end-stage renal disease (ESRD). Failure to mature is nevertheless common, and a substantial proportion of newly created fistulas require an adjunctive procedure before they can be cannulated. Balloon-assisted maturation (BAM) is the most widely used endovascular technique for salvaging such fistulas. Methodology This descriptive case series was conducted at Kidney Hospital and Lifeline Medical Institutions, Jalandhar, India, between July 2024 and December 2024. Consecutive patients undergoing first-time autogenous AVF creation were reviewed at four and eight weeks with clinical examination and Doppler ultrasound. Patients whose fistulas were judged immature were offered BAM. In total, 10 patients underwent the procedure: eight radiocephalic and two brachiocephalic fistulas. Angioplasty was performed under local anesthesia and fluoroscopic guidance through the outflow vein, with the stenosis crossed using a hydrophilic guidewire and dilated sequentially. Written informed consent was obtained from every patient. Results Of the 84 patients undergoing first-time autogenous AVF creation during the study period, 18 (21.4%) had an immature fistula with a demonstrable stenosis at follow-up; eight were managed conservatively, and 10 underwent BAM. The mean age of the BAM cohort was 60.7 years (range = 46-73), and eight (80%) patients were male. Diabetes mellitus and hypertension were present in all 10 patients, and diabetes was the cause of ESRD in eight. Technical success was achieved in all 10 (100%) fistulas. The majority of culprit lesions were located within the juxta-anastomotic venous segment. Completion fistulograms showed a smooth luminal contour, increased venous calibre, and no contrast extravasation along both the treated segment and the entire usable length of the fistula. There were no venous ruptures, access-site hematomas, or post-procedural thromboses, and all 10 fistulas were subsequently cannulated with two needles for hemodialysis. Conclusions In this small series, BAM was a safe and effective adjunct for salvaging stenosed, non-maturing AVFs, with a 100% technical and clinical success rate and no procedural complications. The findings are consistent with larger published cohorts, but the absence of a comparator group, the small sample, and the short follow-up preclude any conclusion about long-term patency; larger prospective studies with defined patency endpoints are required.