"Effect of Perioperative and Short-Term Apixaban Therapy on Arteriovenous Fistula Maturation in Patients With End-Stage Renal Disease: A Randomized Controlled Trial"

End-stage renal disease (ESRD) is a growing global health burden, and the creation of a native arteriovenous fistula (AVF) is the gold standard for vascular access in patients requiring hemodialysis [1]. AVFs offer superior longevity, fewer infectious complications, and lower mortality rates compared to central venous catheters or synthetic grafts [2]. However, a significant limitation to their widespread success is the high rate of early failure, primarily due to failure to mature (FTM). FTM occurs in 20-40% of AVFs, rendering them unusable for dialysis [3].

The maturation process is a complex physiological response to the newly created arteriovenous anastomosis, requiring adequate arterial inflow, venous outflow, and vessel remodeling [4]. Thrombosis during this critical maturation period remains a major cause of early AVF failure [5]. While systemic intraoperative heparin (as discussed in the referenced review) provides transient anticoagulation during the immediate perioperative period, it has a half-life of only 1-2 hours and does not provide prolonged protection during the weeks following surgery when maturation is occurring [6].

To date, no randomized controlled trial has specifically evaluated the role of short-term, protocol-directed apixaban therapy initiated at the time of AVF creation and continued through the maturation period. This study aims to determine whether perioperative and short-term apixaban therapy improves AVF maturation rates without significantly increasing bleeding complications.

2. Research Question (PICO) Population: Adult patients (≥18 years) with ESRD undergoing primary upper extremity AVF creation (radiocephalic, brachiocephalic, or brachiobasilic).

Intervention: Short-term therapeutic apixaban initiated immediately postoperatively and continued for 6 weeks during the maturation period.