The failure of arteriovenous fistula (AVF) maturation is one of the main problems encountered after AVF creation at present. In some situation, such as high-degree stenosis, juxta-anastomotic lesions and lesions at multiple sites of the AVF, transradial or transbrachial access for PTA with sheath placement has been proven effective [8, 10, 11]. In the professor Chee Wui Ong’s research, there were four patients with radial artery occlusion after sheath placement. Although most patients did not exhibit significant clinical manifestations postoperatively, there was still a concern about possible ischemia occurring in the distal extremities in the long run. In our study, we achieved satisfactory outcomes by employing pull-through technique using guide sleeve without sheath insertion for treating immature AVF. It not only reduces the risk of thrombosis, hematoma and pseudoaneurysm associated with sheath placement, but also reduces the complexity of the intervention to a certain degree.

In our follow-up of 62 individuals, we found the 6-month primary patency rates of the PT group and the control group was 76.9%, 70.7% respectively. The results were similar to those described in the professor Chen’s report [12]. Yet, at 12 months, the primary patency rate was much lower than previous results reported in the recent years [13]. This may be due to the fact that previous studies employed techniques like JXAS stenting, cannulation zone stenting and drug coated balloon angioplasty, while our research merely used plain balloon angioplasty. Additionally, during phone follow-up conversations for the reasons of re-intervention, we drew a possible conclusion that some patients chose to intervene earlier to avoid dialysis quality decreasing and thrombus formation. Because many of them received routine color Doppler ultrasound surveillance, which may reveal narrowed vessel diameter or decreased blood flow. This might explain why the 12-months primary patency rate in our study is on the lower side.

Previous studies have confirmed that the patency rate after PTA was influenced by several factors, such as stenosis characteristic and the drug-coated balloon use [5]. In our study, we employed the Cox regression model to analyze whether the route of entry affected the 12-month primary patency rate after invention. The results showed that there was no significant difference between the two groups, even after adjusted the factor, such as age, sex and stenosis site. The same conclusion was drawn upon the analysis of sex, age, and the stenosis site. In other words, it also demonstrated that the pull-through technique using guide sleeve without sheath insertion can also achieve comparable results in promoting radiocephalic AVF maturation.

In our study, all patients in the PT group underwent radial artery puncture guided by ultrasound, which could increase the success rate of puncture and avoid hematomas and occlusion. After successfully puncturing the radial artery, we used a regular 0.035-Inch guidewire to go through the needle sleeve. Once the guidewire was captured out from the sheath in the vein, the balloon could easier pass through the high-degree stenosis lesions or juxta-anastomotic segment. Besides, local pressure was applied for 5 min on the radial artery puncture site, without additional devices. This technique also reduced the medical cost. Meanwhile, it is also important to know that in case of juxta-anastomotic stenosis, the surgical technique could be a valid alternative to the endovascular technique if the venous approach does not allow to enter the proximal radial artery through the anastomosis.

In the follow-up of all included patients, we found that there were two patients int the PT group and 5 patients in the control group still cannot be used 8 weeks after intervention. They eventually chose the tunneled catheter as the dialysis access. All the other AVFs were successfully punctured and used 4–8 weeks after intervention, which confirming that the balloon-assisted maturation technique deem plays a significant role in promoting raidocephalic AVF maturation.

Similarly, when comparing the intervention time of both groups, we found that there was still no statistically difference. However, upon further investigation into all patients’ intervention time, we noticed that the operation time for early PT procedure patients was longer than those who underwent PT procedures later. That could be because, with experience gained from early PT techniques, the operator quickly switched to PT techniques when unable to pass through lesion sites during retrograde vein puncture. And it was also a meaningful measure for reducing radiation exposure time for both patients and operators.