295 - Redefining Arteriovenous Fistula Maturation with a Physiology First Protocol

Purpose: Hemodialysis initiation depends on successful arteriovenous fistula(AVF) maturation.Time to cannulation is highly variable due to delayed maturation and potential need for salvage procedures.Yet, the current paradigm to assess AVF maturation is fixed on time.

Materials and Methods: We conducted a quality improvement initiative to reduce AVF maturation variability through early algorithmic-driven identification of salvageable AVFs using patient-specific physiological and anatomical data.To reduce the need for high pressure balloon angioplasty(PTA) in non-maturing AVFs, we incorporated kinetic endovascular micro-incision creation(KEMIC) with the FLEX Vessel Preparation System(VentureMed Group) to assist maturation.

Results: The Physiology First protocol:At Week 2 standardized ultrasound surveillance, if brachial artery(BA) flow is declined or failed to improve from day-of-creation values, or if vein diameter, depth, or waveform quality does not demonstrate appropriate progression, the patient proceeds to diagnostic angiogram and intervention(KEMIC+PTA).If a patient shows adequate interval improvement in flow, waveform, and diameter but does not yet meet cannulation benchmarks, follow-up imaging is scheduled for Week 4. If, however, the patient meets cannulation criteria at Week 2,then the dialysis clinic is notified to begin cannulation within 1–2 weeks,without requiring a formal return visit.At Week 4,a patient who has continued improvement and meets all metrics is cleared for cannulation.If maturation has stalled, then the structured salvage algorithm is applied(KEMIC+PTA±DCB,or lipectomy/transposition if vein depth >6 mm).





To demonstrate protocol application, 60 AVFs created by a single surgeon in a community-based hospital were prospectively followed from January to May 2025.Unassisted AVF maturation occurred in 51.7% of the cases(31/60). Of the non-mature AVFs, the Physiology First protocol identified 14 salvageable AVFs. All salvageable AVFs qualified for KEMIC+PTA intervention.Functional clinical maturation was achieved in all assisted AVFs(14/14; 100%) providing an overall functional clinical maturation rate of 75%(45/60) of AVFs.Median time to use was 47 days for unassisted and 88 days for salvaged AVFs.

Conclusion: We provide proof-of-concept of a structured algorithm-driven approach to enable predictable AVF maturation rates through early detection, timely intervention, and tailored subtype management. Further validation of this new clinical protocol is ongoing to determine its adoption into standard clinical practice.