Introduction

The arteriovenous fistula (AVF) is the preferred vascular access for chronic hemodialysis, yet maturation failure remains a significant barrier, with up to 60% of newly created AVFs failing to mature in some cohorts [1]. Although the traditional "rule of sixes" (flow ≥600 mL/min and vein diameter ≥6 mm) has historically been used to assess AVF maturation, the 2019 Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines emphasize clinical usability and individualized assessment rather than fixed ultrasound thresholds alone [1]. While overt stenosis is the most commonly recognized cause of failure to mature (FTM), a substantial proportion of non-maturing fistulas lack angiographically apparent lesions [1]. This observation suggests that disturbed flow dynamics and vascular geometry may contribute to maturation failure despite a patent venous lumen. Functional hemodynamic obstruction refers to impaired blood flow resulting from alterations in flow velocity and wall shear stress without an anatomically visible stenosis. Such disturbances may interfere with the outward vascular remodeling required for successful AVF maturation [2,3].

The intersection of cardiac implantable electronic devices (CIEDs) and hemodialysis access adds further complexity. Transvenous leads are associated with central venous stenosis in 11-36% of patients, with symptomatic stenosis occurring in up to 71% of patients when the AVF and lead are ipsilateral [3]. Accordingly, current recommendations favor contralateral placement whenever feasible [3].

To our knowledge, reports describing delayed AVF maturation that improved following transvenous lead extraction despite the absence of angiographically apparent central venous stenosis remain limited. This case explores the hypothesis that an ipsilateral transvenous implantable cardioverter defibrillator (ICD) lead may have contributed to delayed AVF maturation through functional hemodynamic disturbance rather than overt mechanical obstruction and highlights the potential implications of ICD platform selection for preservation of dialysis vascular access.