Southern Association For Vascular Surgery

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Early Results of a Single-Center Experience with Endovascular Arteriovenous Fistula Creation for Hemodialysis access using the WavelinQ System
Michael A Lopez1, Elke O. Ulloa2, Miguel A Lopez-Viego1, George Mueller2, Reagan L. Ross1
1University of Miami Miller School of Medicine, Atlantis, FL;2Bethesda Hospital Baptist Health System, Boynton Beach, FL

BACKGROUND: Endovascular AV fistula (EndoAVF) creation is a new, minimally invasive option for hemodialysis access creation. The NEAT and FLEX Trials demonstrated that it is feasible to construct an EndoAVF utilizing the WavelinQ system. The results of NEAT and FLEX trials in terms of initial success (greater than 97%) and functional usability for dialysis (64% and 96%, respectively) were promising. This study investigated the clinical reproducibility of creating an EndoAVF using the WavelinQ system with similar results.
METHODS: Seventy-six patients from December 1, 2018 through August 31, 2020 underwent a planned creation of an EndoAVF using the WavelinQ system. Immediate technical success, procedural complications and postoperative ultrasound diameter, depth and flow rates were documented. Initial successful hemodialysis through the EndoAVF, as well as achieving metrics suitable for initiating dialysis in the pre-dialysis population were also recorded. Special attention was given to the outcome of those patients who in the initial procedure either failed to create an EndoAVF or those in whom the AVF failed to mature to satisfactory metrics for needle placement.
RESULTS: Fifty-five of the 76 patients (72%) had a successful EndoAVF created, and 35 of those patients have had at least 90 days of fistula maturation during this time frame. Ten patients have used their EndoAVF for dialysis. Fifteen patients have achieved satisfactory metrics (600 mL/min flow at the site of needle placement, 6 mm diameter and distance from the skin of less than 6 mm) to initiate dialysis but are either pre-dialysis or are utilizing other modalities of renal replacement therapy. Our ability to provide a usable EndoAVF within 90 days was 71% (25/35) when we were successful in the initial creation. There were 21 de novo failures. Of these 21 patients, 16 required an open AV fistula creation, and 2 patients underwent AV graft placement. One patient is awaiting imminent transplant, and 2 patients refused creation of an open AV fistula.Ten patients had an initially successful creation of an EndoAVF but subsequently failed to mature to acceptable cannulation metrics. Five patients underwent creation of an open ipsilateral AV fistula. Two patients had AV grafts placed successfully while 3 patients are awaiting AV graft placement while on catheter-based dialysis.
CONCLUSIONS: We can conclude that the WavlinQ system for EndoAVF creation is a viable option for hemodialysis access, however compared to landmark trials, the limitations from our study appear to be the technical difficulties in successfully creating the initial EndoAVF. Our initial EndoAVF creation success rate was 72%. This fell short of the FLEX and NEAT trialís results of 97% and 98% respectively. Operative technique and screening parameters have been modified to improve initial success, but further research must be done evaluating preoperative screening protocols as well as adjustments in operative technique to improve initial success at creating an EndoAVF. An algorithm for management of initial failures is also necessary. This study demonstrates that when the initial EndoAVF creation is successful, functional usability was achieved in 71% of patients at 90 days post operatively. These findings within the range of results reported in the NEAT and FLEX trials. We believe the EndoAVF has a useful place in the armamentarium of the dialysis access surgeon. We have found that when successful, patient satisfaction is extremely high and that our local dialysis community has welcomed the addition of this innovation.


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