Unanticipated late maturation of an arteriovenous fistula after creation of separate graft access

Autogenous arteriovenous vascular access with an arteriovenous fistula (AVF) is the gold standard for attaining long-term hemodialysis vascular access (1). When compared to prosthetic arteriovenous grafts (AVGs) and tunneled hemodialysis catheters, an AVF has less frequent rates of thrombosis, stenosis, and infection. Additionally, AVFs are observed to provide a more long-term and stable access for hemodialysis patients (2,3). A major obstacle to successful AVF creation is maturation, as about 30–50% of AVFs fail to mature. Maturation mostly occurs 4 to 6 weeks after the initial fistula surgery but that timeframe can vary with the average time ranging from 1 to 4 months. Thus, maturation of AVFs can be a relatively unpredictable process (4). Adequate AVF maturation is based on the National Kidney Foundation’s Kidney Dialysis Outcomes Quantitative Initiative (KDOQI) guidelines which define a viable fistula as one that resides approximately 0.6 cm from the skin surface, has a flow >600 mL/min, and has a diameter >0.6 cm (5). AVFs that do not mature adequately within that time frame may be abandoned altogether and classified as early or primary failure (6,7). Patients with primary AVF failure consequently rely more on grafts and catheters, exposing them to greater risks. Because maturation is a highly unpredictable and variable process, many AVFs that have not matured after several months are not followed up. Only a few cases have been witnessed to show delayed maturation of a fistula after abandonment after classification as primary failure and without any prior surgical intervention to salvage the immature fistula. However, no documentation currently exists to describe such findings