{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,20]],"date-time":"2026-07-20T07:07:03Z","timestamp":1784531223423,"version":"3.55.0"},"reference-count":10,"publisher":"SAGE Publications","issue":"4","license":[{"start":{"date-parts":[[2026,2,24]],"date-time":"2026-02-24T00:00:00Z","timestamp":1771891200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["J Vasc Access"],"published-print":{"date-parts":[[2026,7]]},"abstract":"\n Background:<\/jats:title>\n Arteriovenous fistula (AVF) non-maturation is a major challenge in Western countries (rates up to 60%), yet clinical maturation rates in Japan are exceptionally high. This discrepancy is not fully understood. We hypothesized that this success is not due to adherence to anatomical \u201cRule of 6s\u201d criteria, but rather to a unique clinical practice prioritizing shallow vessel depth.<\/jats:p>\n <\/jats:sec>\n \n Methods:<\/jats:title>\n We conducted a single-center, retrospective study of 22 consecutive incident hemodialysis patients with a temporary catheter who underwent AVF construction. All patients were cannulated exclusively with plastic cannulas by residents (3rd\u20135th year) after a collaborative assessment with the surgeon and pre-cannulation ultrasound confirmation. The primary outcome was the clinical maturation rate. Secondary outcomes included the anatomical maturation rate based on the \u201cRule of 6s\u201d (FV >600\u2009mL\/min, Diameter >6\u2009mm, Depth <6\u2009mm) and the cannulation site.<\/jats:p>\n <\/jats:sec>\n \n Results:<\/jats:title>\n \n The clinical maturation rate was exceptionally high at 95.5% (\n N<\/jats:italic>\n \u2009=\u200921\/22). The median time to fistula use was 8\u2009days. In stark contrast, the anatomical maturation rate (\u201cRule of 6s\u201d) was only 4.8% (\n N<\/jats:italic>\n \u2009=\u20091\/21). While 100% of sites met the depth criterion (<6\u2009mm; mean 1.9\u2009mm), most failed the size criterion (mean 4.0\u20134.3\u2009mm). The elbow area was heavily utilized, accounting for 90.5% of blood removal or return sites. The median QB at discharge was low at 180\u2009mL\/min.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusion:<\/jats:title>\n High AVF clinical maturation rates were achieved rapidly in this Japanese cohort despite near-total failure to meet \u201cRule of 6s\u201d criteria for size and flow. This success was strongly associated with a clinical practice prioritizing shallow vessel depth\u2014often found in the elbow joint\u2014a strategy enabled by plastic cannulas and low QB settings. Vessel depth, rather than diameter or flow, appears to be the most critical anatomical factor for clinical success in this setting.<\/jats:p>\n <\/jats:sec>","DOI":"10.1177\/11297298261420933","type":"journal-article","created":{"date-parts":[[2026,2,24]],"date-time":"2026-02-24T11:48:41Z","timestamp":1771933721000},"page":"1748-1755","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["Discrepancy between clinical maturation rate and Rule of 6s criteria in Japanese arteriovenous fistulas: A focus on vessel depth and cannulation site"],"prefix":"10.1177","volume":"27","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4251-5315","authenticated-orcid":false,"given":"Kotaro","family":"Suemitsu","sequence":"first","affiliation":[{"name":"Department of Nephrology, Osaka Keisatsu Hospital, Osaka, Japan"},{"name":"Department of Internal Medicine, Division of Kidney and Dialysis, Kansai Rosai Hospital, Amagasaki, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yoshiaki","family":"Tanioka","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Division of Kidney and Dialysis, Kansai Rosai Hospital, Amagasaki, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ayaka","family":"Shirasaki","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Division of Kidney and Dialysis, Kansai Rosai Hospital, Amagasaki, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ryoko","family":"Honda","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Division of Kidney and Dialysis, Kansai Rosai Hospital, Amagasaki, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yuma","family":"Ohnishi","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Division of Kidney and Dialysis, Kansai Rosai Hospital, Amagasaki, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Naomi","family":"Ota","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Division of Kidney and Dialysis, Kansai Rosai Hospital, Amagasaki, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Masaaki","family":"Izumi","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Division of Kidney and Dialysis, Kansai Rosai Hospital, Amagasaki, Japan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2026,2,24]]},"reference":[{"key":"e_1_3_3_2_2","doi-asserted-by":"publisher","DOI":"10.1053\/j.ajkd.2019.12.001"},{"key":"e_1_3_3_3_2","doi-asserted-by":"publisher","DOI":"10.1001\/jama.299.18.2164"},{"key":"e_1_3_3_4_2","doi-asserted-by":"publisher","DOI":"10.1053\/j.ajkd.2017.09.012"},{"key":"e_1_3_3_5_2","volume-title":"2024 USRDS annual data report: epidemiology of kidney disease in the United States","author":"United States Renal Data System","year":"2024","unstructured":"United States Renal Data System. 2024 USRDS annual data report: epidemiology of kidney disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2024."},{"key":"e_1_3_3_6_2","article-title":"Clinical practice guidelines for vascular access","author":"Vascular Access 2006 Work Group","year":"2006","unstructured":"Vascular Access 2006 Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006; 48 Suppl 1: S176\u2013S247.","journal-title":"Am J Kidney Dis"},{"key":"e_1_3_3_7_2","doi-asserted-by":"publisher","DOI":"10.1159\/000529991"},{"key":"e_1_3_3_8_2","doi-asserted-by":"publisher","DOI":"10.1177\/1129729817747535"},{"key":"e_1_3_3_9_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jvs.2020.09.033"},{"key":"e_1_3_3_10_2","doi-asserted-by":"publisher","DOI":"10.1177\/11297298211011375"},{"key":"e_1_3_3_11_2","doi-asserted-by":"publisher","DOI":"10.1159\/000516212"}],"container-title":["The Journal of Vascular Access"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/11297298261420933","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/full-xml\/10.1177\/11297298261420933","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/11297298261420933","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,20]],"date-time":"2026-07-20T06:48:55Z","timestamp":1784530135000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1177\/11297298261420933"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,24]]},"references-count":10,"journal-issue":{"issue":"4","published-print":{"date-parts":[[2026,7]]}},"alternative-id":["10.1177\/11297298261420933"],"URL":"https:\/\/doi.org\/10.1177\/11297298261420933","relation":{},"ISSN":["1129-7298","1724-6032"],"issn-type":[{"value":"1129-7298","type":"print"},{"value":"1724-6032","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,24]]}}}