Comparison of ultrasound features and lesion sites in dysfunctional arteriovenous fistula

Figures & data

Figure 1. Ultrasound features of typical AVF lesions.

(A) Type intima-dominant. Intimal hyperplasia at the proximal vein: distance shows the thickness of the intima (1.5 mm), and the minimum luminal diameter is 1.3 mm. The PSV at the stenosis site is 567 cm/s. (B) Type Non-intima-dominant: distance shows the thickness of intima (0.3 mm), and minimum luminal diameter is 1.7 mm. The PSV at the stenosis site is 592 cm/s. (C) Type Valve obstruction (In color mode). The valve is stiff, and the lead vascular lumen shows severe stenosis. The minimum luminal diameter is 1.0 mm. The white curved arrow points to the stiff valve. The PSV at the stenosis site is 534 cm/s. (D) Type vascular calcification. Vein calcification at venous outflow near the anastomosis, and the minimum luminal diameter is 0.8 mm. The PSV at the stenosis site is 511 cm/s. Sheet-like calcified plaques break into the lumen of the vessel and are hyperechoic. The white straight arrows point to calcified plaques. The border between intima and lumen is marked on the figures as dotted lines, * residual lumen, + intima. AVF: arterial-venous fistula; PSV: peak systolic velocity.

Table 1. Baseline demographics, clinical, and laboratory examination characteristics of all 185 patients in the cohort.

Variables	Intima dominant	Non-Intima dominant	Valve obstruction	Vascular Calcification	Mixed	p/x^2
No. of patients	100	36	22	11	16
Age (years)	59.67 ± 11.97	59.17 ± 11.00	57.14 ± 12.22	55.36 ± 12.81	53.88 ± 9.89	0.324
Sex (Female/Male)	48/52	13/23	12/10	7/4	8/8	0.564
Duration of HD	23(11, 48)	38(23, 50)	50(12, 67)	86(49, 140)	55(18, 96)	0.000^a
AVF use time	15(9, 30)	28(14, 50)	50(13, 65)	77(49, 110)	18 (11, 58)	0.000^a
AVF location n (%)						0.035^b
Upper arm	10	4	4	0	6
Forearm	90	32	18	11	10
PTA times						0.034^b
0	88	31	17	7	10
≥1	12	5	5	4	6
Baseline disease
Hypertension	88 (88.0)	32 (88.89)	19 (86.36)	11 (100)	15 (93.75)	0.872^b
Diabetes n (%)	42 (42.0)	7 (19.44)	6(27.27)	3 (27.27)	2 (12.5)	0.019^b
Coronary artery disease	46(46)	13 (36.11)	5(22.73)	7 (63.64)	7 (43.75)	0.154^b
Cerebrovascular disease	12 (12)	2 (5.56)	1 (4.55)	3 (27.27)	2 (12.5)	0.265^b
PAD	1(1)	0	0	0	0	–
hs-CRP (mg/L)	8.07 ± 1.45	6.89 ± 1.54	9.10 ± 1.17	3.16 ± 0.41	3.60 ± 0.36	0.194
≥3	55	18	14	10	14	0.013^b
<3	45	18	8	1	2
PTH (pg/mL)	320.81 ± 109.70	307.90 ± 95.14	350.76 ± 82.55	569.42 ± 156.01	353.41 ± 102.07	0.048
Calcium (mmol/L)	2.19 ± 0.23	2.25 ± 0.27	2.23 ± 0.23	2.31 ± 0.26	2.27 ± 0.25	0.340
Phosphorus	1.80 ± 0.55	2.02 ± 0.58	1.66 ± 0.44	1.93 ± 0.45	1.93 ± 0.40	0.100
Alb	38.83 ± 4.92	40.27 ± 4.52	39.80 ± 6.14	40.41 ± 3.19	40.76 ± 5.62	0.053
Hb	101.59 ± 18.86	108.79 ± 22.21	108.91 ± 18.69	115.27 ± 18.91	110.47 ± 16.35	0.077
LVEF	58.34 ± 8.92	59.44 ± 7.93	59.59 ± 8.03	60.23 ± 5.97	55.69 ± 9.99	0.569
SBP	145.49 ± 20.34	140.99 ± 18.85	142.32 ± 26.80	143.05 ± 19.94	143.00 ± 16.39	0.832
DBP	81.46 ± 10.43	82.70 ± 10.82	83.39 ± 12.86	86.68 ± 14.57	79.25 ± 9.51	0.454

Note: HD: hemodialysis; AVF: arterial-venous fistula; PTA: percutaneous transluminal angioplasty; hs-CRP: high-sensitivity C-reactive protein; PTH: parathyroid hormone; Alb: Albumin; Hb: hemoglobin; LVEF: left ventricular ejection fraction; SBP: systolic blood pressure; DBP: dialytic blood pressure; PAD: peripheral arterial disease.

Table 2. Ultrasound characteristics of different AVF lesion types (n = 185).

Variables	Intima-dominant	Non-Intima dominant	Valve obstruction	Vascular calcification	Mixed	p value
Vascular access	100	36	22	11	16
Minimum luminal diameter (mm)	1.28 ± 0.64	1.30 ± 0.63	1.57 ± 0.60	2.03 ± 0.48	1.33 ± 0.89	0.013
Diameter of brachial artery (mm)	5.03 ± 0.87	5.31 ± 0.97	5.51 ± 1.36	5.51 ± 1.14	5.08 ± 0.99	0.333
Diameter of inflow artery near the anastomosis	2.77 ± 0.88	3.14 ± 0.93	2.92 ± 1.17	2.96 ± 1.52	3.53 ± 1.57	0.060
Lesion type						0.146^a
Type I	64	26	13	9	10
Type II	16	7	6	0	2
Type III	4	0	1	0	3
Mixed	16	3	2	2	1
Calcification in AVF-n (%)	19(19.0)	14 (38.89)	12 (54.55)	11(100)	9 (56.25)	0.000^a
Calcification at PTA sites-n (%)	0 (0)	5 (13.89)	6(27.27)	11(100)	1 (6.25)	0.000^a
PTA Pressure -n (atm)	100(17.81 ± 4.30)	36(16.90 ± 4.38)	22(16.02 ± 4.12)	11(16.37 ± 4.55)	16(16.23 ± 4.75)	0.787
Qa after PTA (ml/min)	770.29 ± 203.3	756.0 ± 185.27	792.10 ± 175.56	769.15 ± 201.14	759.16 ± 198.15	0.832

Note: Type I: Stenosis near the anastomosis; type II: Stenosis in the region of the draining vein, particularly in the region of the puncture; type III: Stenosis in the venous confluence site or the central vein, particularly in the region of the cephalo-axillary vein or the subclavian-nominal vein); mixed type: AVF with two or more types of stenosis; AVF: arteriovenous fistula; Qa: Blood flow of AVF; PTA: percutaneous transluminal angioplasty.

Figure 2. Kaplan–Meier survival analysis of AVF primary patency after PTA.

(A) Kaplan–Meier survival analysis of the type of AVF stenosis location on AVF primary patency after PTA; (B) Kaplan–Meier survival analysis of the type of ultrasound appearance on AVF primary patency after PTA; type I: stenosis near the anastomosis; type II: stenosis in the region of the draining vein, particularly in the area of the puncture; type III: stenosis in the venous confluence site or the central vein, particularly in the region of the cephalo-axillary vein or the cephalic arch); mixed type: AVF with two or more types of stenosis. AVF: Arterial-venous fistula; PTA: percutaneous transluminal angioplasty.

Table 3. Multivariate Cox regression model of factors predicting post-intervention primary patency of AVF in patients receiving HD (n = 185).

Factors	Univariate analysis			Multivariate analysis
	HR	95%CI	P	HR	95%CI	p
Age (years)	1.021	0.998–1.046	0.064	1.028	1.000–1.056	0.076
Diabetes (No/Yes)	0.849	0.493–1.460	0.553	1.111	0.560–2.207	0.763
Duration of HD (months)	1.000	0.994–1.006	0.959	0.991	0.979–1.003	0.133
AVF use time (months)	1.001	0.993–1.009	0.786	1.011	0.995–1.027	0.187
Vascular calcification (no/yes)	1.497	0.838– 2.674	0.173	2.014	1.104–3.676	0.023
Calcification at PTA sites (no/yes)	1.728	1.370–4.435	0.360	3.306	1.129–9.854	0.033
Inflow arterial diameter (mm)	0.925	0.724–1.182	0.534	0.950	0.725–1.561	0.075
Minimum luminal diameter (mm)	0.988	0.672–1.453	0.952	1.095	0.727–1.649	0.665
Dilatation pressure (atm)	1.007	0.948–1.052	0.891	1.013	0.961–1.070	0.621
PTA times (0/≥1)	0.196	0.108–0.358	0.000	0.101	0.046–0.222	0.000
Type of lesion location			0.023			0.612
Type I	1.730	0.617–4.852	0.297	1.369	0.498–4.609	0.567
Type II	2.051	0.642–6.553	0.226	1.294	0.350–4.332	0.676
Type III	7.657	1.898–30.883	0.004	2.354	0.447–11.605	0.293
Mixed	Ref.			Ref.
Ultrasound Appearance
Intima dominant	0.487	0.231–1.027	0.640	0.490	0.210–1.142	0.532
Non-Intima dominant	0.528	0.225–1.240	0.123	0.576	0.227–1.463	0.098
Valve obstruction	0.506	0.187–1.366	0.345	0.457	0.155–1.343	0.246
Calcification	0.431	0.116–1.603	0.269	0.513	0.131–2.008	0.154
Mixed	Ref.		0.579	Ref.		0.338
PTH (pg/mL)	1.001	1.000–1.001	0.023	1.001	1.000–1.002	0.024
Phosphorus (mmol/L)	1.400	0.896–2.186	0.139	1.132	0.611–2.100	0.693
Hb (g/L)	1.010	0.996–1.023	0.155	1.022	1.004–1.039	0.136

Note: type I: stenosis near the anastomosis; type II: stenosis in the region of the draining vein, particularly in the area of the puncture; type III: stenosis in the venous confluence site or the central vein, particularly in the region of the cephalo-axillary vein or the subclavian-brachiocephalic vein); mixed type: AVF with two or more types of stenosis. AVF: arterial-venous fistula; PTA: percutaneous transluminal angioplasty; HD: hemodialysis; PTH: parathyroid hormone; Hb: hemoglobin.

PTA times indicates the number of times patients are treated with PTA for AVF dysfunction within the life of the AVF.

Data availability statement

All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.

PTA times indicates the number of times patients are treated with PTA for AVF dysfunction within the life of the AVF.

Data are expressed as mean ± standard deviation for normally distributed measures and as median (interquartile range) for non-normally distributed measures, except where noted. a: Mann–Whitney U non-parameter test; b: Fisher exact probability method is used for comparison.

Data forms are expressed as mean ± standard deviation for normally distributed measures and median for non-normally distributed measures, except where noted; a: Fisher exact probability method is used for comparison.