SIR’s Renal and Genitourinary Clinical Specialty Council has formed a workgroup, in collaboration with the SIR Statements and Guidelines Division, to establish a society-based consensus recommendations for the creation and maturation of percutaneous arteriovenous fistulas (pAVFs) for hemodialysis access.
This document, which is available online at jvir.org, provides an overview of best practices for the development of a pAVF program, from patient selection to billing guidance.
IR Quarterly spoke with Bart L. Dolmatch, MD, FSIR, chair of the SIR Renal and Genitourinary Clinical Specialty Council, and Andrew J. Gunn, MD, FSIR, who wrote the document.
Why is it important to have a practice guidance document on pAVF creation?
Bart L. Dolmatch, MD, FSIR
Bart L. Dolmatch, MD, FSIR: First, SIR members should recognize that the world of pAVF creation has had a seismic shift following the recent announcement that the Ellipsys device will no longer be supported and is not available for anyone who wants to start a program. This happened in the midst of the pAVF practice guidance document (PGD) creation. So, at this time, the only option available for creation of a pAVF is the WaveLinQ system.
Meanwhile, there’s innovation on the way (currently in clinical trials) that may introduce another system for creation of pAVFs. There’s also some talk that the Ellipsys device may return to the market. With that said, there are IRs who have already developed successful pAVF practices that meet the needs of patients who require hemodialysis and have suitable anatomy for non-surgical AVF creation. Although the landscape of pAVF is shifting, we felt that a PGD would be helpful to summarize how successful percutaneous AVF programs have been developed and share this information with IRs who are early into the development of a pAVF program.
How was the pAVF PGD produced?
Andrew J. Gunn, MD, FSIR
Andrew J. Gunn, MD, FSIR: We tapped the expertise of IRs who have active pAVF program, as well as those who are experts on treating patients who require hemodialysis. Then, we divided the pAVF PGD into sections and assigned small writing groups to each of these sections. Once all of the sections were written, everyone from the groups participated in editing the work into the final comprehensive PGD.
The Guidance Statements were written using information within the PGD sections, and each of the Guidance Statements went through a Delphi process with at least 80% consensus.
Additionally, we asked Andre Uflacker, MD, a SIR member who is a very talented anatomic artist, to create some of the figures for the final pAVF PGD. His work is exemplary and addresses some of the complex anatomic features that are important when creating pAVFs. We would also like to acknowledge and thank Kaeli Vandertulip from the SIR for her administrative support.
Do you feel any of the guidelines within the PGD may be surprising to readers?
Dr. Dolmatch: Probably the most important guidelines are related to the creation of pAVFs as a “program,” not just a procedure. While creation of pAVFs is done with a high degree of success, post-procedure follow up and secondary procedures are often required to make many pAVFs reliably useful for hemodialysis.
Dr. Gunn: The writing group also felt that guidelines for performing brachial plexus blocks would be helpful for IRs, since regional nerve blocks can facilitate pAVF creation in many ways. Many IRs may not know how to do a regional brachial plexus block.
Are there any key points you’d like readers to take away from these guidelines?
Dr. Dolmatch: As mentioned, the landscape of pAVF creation and maturation is evolving. I don’t think that pAVFs are “dead,” and would advise IRs to consider starting a program if there is a clinical need, referral pathways that can be established and the interest to stay with the patient after a pAVF has been created to assure that it can be used successfully for hemodialysis.
The document provides not only clinical guidance, but also insight into building a full AVF program, including coding and billing and patient recruitment. Why did the authors choose to include broader guidance on practice development, as well as clinical practice guidelines?
Dr. Gunn: If a pAVF cannot be used for hemodialysis, and if it’s not fiscally viable for a practice, then there’s no point in doing the procedure. Assuring a clinically functional pAVF with adequate reimbursement requires a program. This is the thrust of the pAVF PGD.
Is there anything else you’d like readers to know about the creation, content or impact of this document?
Dr. Dolmatch: This pAVF PGD is a first draft. As time goes by, and with future innovation, there may be significant changes to the document. But as already stated, creation of pAVFs requires commitment to achieving fistulas that function well for hemodialysis, and this requires a program. To that end, many of the Guidance Statements will probably remain relevant into the future.
Read the Practice Guidance Document in the Journal of Vascular and Interventional Radiology.
Dolmatch BL, Gunn AJ, Arslan B, Gallo V, Haddad M, Kennedy RJ, Meek ME, Quencer KB, Rajan DK, Razdan RN, Repko BM, Werder G, Uflacker A, Wilkins LR, Vandertulip K. A Society of Interventional Radiology Practice Guidance Document on Percutaneous Arteriovenous Fistulas for Dialysis Access. JVIR (2025), doi: doi.org/10.1016/j.jvir.2025.08.019.
SIR members can look forward to future PGDs that include prostate artery embolization, venous-origin chronic pelvic pain, HCC, PPH, and pediatric vascular access. These documents will help to provide guidance and direction to our members on key clinical decisions, work to highlight evidence surrounding the procedures we perform, and highlight areas for future research.
