Risk of Performing Angioplasty on AVF During Bacteremia Not Associated with AVF
Angioplasty on an AVF should be deferred during active bacteremia, even when the bacteremia is not AVF-related, due to the substantial risk of seeding the access site and converting a functioning fistula into an infected one that may require ligation.
Primary Risk: Access Infection and Seeding
Any invasive procedure on vascular access during bacteremia carries risk of bacterial seeding to the intervention site, which can convert a sterile, functioning AVF into an infected access 1, 2.
Infected AVFs, even when initially salvageable, have an 18% re-infection rate within one year and may ultimately require ligation in cases of rupture or uncontrolled sepsis 1.
Bacteremia in dialysis patients can lead to metastatic complications including endocarditis, as documented in cases where even routine AVF puncture during bacteremia resulted in tricuspid valve endocarditis with septic pulmonary emboli 2.
Consequences of AVF Infection
When AVFs become infected, surgical exploration and removal of infected segments is often necessary, as the native vessel acts as a nidus for persistent infection 3.
Infected AVF complications include life-threatening rupture, hemorrhage, exsanguination, and sepsis 3, 1.
In one surgical series, 14 of 64 infected AVFs (22%) required complete ligation rather than salvage, with 9 cases presenting with active bleeding from infected ruptured fistulas 1.
Impact on Access Survival and Patient Outcomes
Loss of a functioning AVF forces reliance on tunneled catheters, which have dramatically higher infection rates (1.6 per 1,000 catheter-days) and access loss rates (48-107 per 100 patient-years) compared to AVFs (2-14 per 100 patient-years) 4.
AVF use is associated with 69% lower cardiovascular mortality compared to catheter use (HR 0.69,95% CI 0.68-0.70), making preservation of existing AVF function critically important 3, 5.
The relative risk of bacteremia with AVFs is 7 times lower than with catheters, emphasizing the importance of not converting a low-risk access to a high-risk catheter situation 4.
Clinical Algorithm for Decision-Making
Assess bacteremia severity and source:
- Identify the organism and source of bacteremia 2
- Determine if appropriate antibiotics have been initiated and duration of therapy 1
Evaluate AVF urgency:
- If AVF is thrombosed or completely non-functional requiring immediate intervention for dialysis adequacy, the risk-benefit calculation changes 3, 6
- If AVF is stenotic but still providing adequate dialysis, defer angioplasty until bacteremia clears 6, 7
Timing of intervention:
- Wait for documented clearance of bacteremia with negative blood cultures and completion of appropriate antibiotic course before performing elective angioplasty 1, 2
- For urgent/emergent situations where dialysis cannot be performed, temporary catheter placement is safer than risking AVF infection 4, 8
Supporting Evidence for Deferral
Prophylactic PTA of functioning AVF stenosis improves survival by fourfold and decreases access-related morbidity by halving hospitalization risk, but these benefits are negated if the procedure results in access infection 6.
PTA has 100% technical success and 97% clinical success rates in appropriate candidates, but performing during bacteremia introduces unnecessary infection risk that compromises these excellent outcomes 7.
AVF maturation failure already occurs in 20-60% of cases, making preservation of existing functional AVFs paramount, even if this means temporary delay of optimization procedures 4.
Critical Pitfall to Avoid
Do not proceed with angioplasty simply because the bacteremia source is "not related" to the AVF - any bacteremia creates risk of hematogenous seeding during instrumentation, and the consequences of converting a functioning AVF to an infected one are catastrophic for long-term dialysis access 1, 2.