Transradial intervention for native fistula failure

Snuffbox distal transradial access (dTRA) for arteriovenous fistuloplasty in Singapore: Going distal is safe

AIM

Arteriovenous fistula (AVF) dysfunction resulting from stenosis or occlusion, is a prevalent issue in end-stage renal failure patients reliant on autogenous AVFs for dialysis. Recently, a distal transradial approach (dTRA) has emerged, offering advantages such as diminished access site complications, better patient comfort and reduced risk of radial artery occlusion. Our study seeks to assess the effectiveness, outcomes and complication rates of employing dTRA for arteriovenous fistuloplasty in Singaporean patients.

METHODS

A retrospective review of all dTRA fistuloplasties performed on dysfunctional or slow to mature AVFs from 2017 to 2023 in our institution was performed. Patients with a distal radial artery measuring 2 mm or more with no evidence of occlusion or thrombosis were included. Patients who required central venoplasty or cutting balloon angioplasty were excluded. Outcome measures included technical success, mean procedure duration, complications and post-intervention primary patency at 1, 3 and 6 months. Patients were followed up for 12 months post-intervention.

RESULTS

A total of 37 patients were included. 97.3% of patients undergoing dTRA fistuloplasty had radiocephalic fistulas while 2.7% had brachiobasilic fistulas. There was 100% technical success (defined as success in radial artery cannulation, sheath insertion and crossing of stenotic lesions) in our study as all patients successfully underwent fistuloplasty via dTRA approach. One-month patency rate was 97.4%, 3-month patency rate was 92.1% and 6-month patency rate was 86.8%. There were no immediate complications (haematoma, infection, bleeding, pseudoaneurysm, occlusion) of the radial artery post-intervention.

CONCLUSION

Our paper illustrates the safety and efficacy of utilising dTRA for arteriovenous fistuloplasty. This approach offers distinct benefits in addressing non-mature or dysfunctional distal forearm arteriovenous fistulas and should be taken into account in anatomically suitable cases.

Trans-radial percutaneous intervention for thrombosed hemodialysis access: A single-center experience

BACKGROUND

Traditionally, percutaneous transluminal angioplasty (PTA) is a first-line approach for stenosed dialysis accesses and has been performed through the non-thrombosed vein segment. For thrombosed accesses, thrombectomy (whether open or percutaneous) is a standard approach. The primary objective of our study is to determine the clinical and technical outcomes of the trans-radial approach of PTA among thrombosed dialysis accesses, in terms of safety and feasibility, technical and clinical aspects and factors influencing them, as well as assisted primary patency, secondary patency at 6 and 12 months.

METHODS

This is a single-center retrospective study that included 150 patients over 3 years. About 123 patients underwent successful percutaneous balloon angioplasty through the radial access.

RESULTS

We report an overall technical and clinical success rate of 82%, assisted primary patency rate of about 90.25% at 3 months, 82.93% at 6 months, 73.18% at 1 year, and secondary patency rate of 94% at 1 year. Twenty-seven patients were referred for surgical revisions/creation of a new fistula for reasons like inability to pass wire (6 patients), unfavorable anatomical variations like aneurysms at the proximal segments (5 patients), inability to cross the fistula (5 patients), and persistent fistula dysfunction with no flow after initial balloon dilatation (11 patients). Three patients had hematoma at the radial access site (2.5%) while two patients had the AV fistula segment rupture and were successfully treated conservatively.

CONCLUSION

We conclude that PTA through the trans-radial approach to completely thrombosed hemodialysis accesses is a good alternative to transvenous access and has a very good assisted primary patency and secondary patency at 1 year without major complications.

Management of Immature Arteriovenous Fistulas

In patients requiring long-term hemodialysis for chronic kidney disease, an arteriovenous fistula is the preferred mode of hemodialysis access over synthetic arteriovenous graft or hemodialysis catheters. The National Kidney Foundation recommended in their Kidney Dialysis Outcomes Quality Initiative (KDOQI) Clinical Practice Guidelines that the creation of an autogenous arteriovenous fistula should initially be sought whenever possible. In 2003, a program named the Fistula First Breakthrough Initiative was initiated in the U.S. to increase the use of arteriovenous fistula for hemodialysis and to ultimately surpass the goal of 50% fistula use in incident and 40% fistula use in prevalent hemodialysis patients per recommendation by KDOQI Guidelines. While this goal was achieved, the encouraged creation of arteriovenous fistulas saw a rise in fistulas that failed to mature. Researchers have focused on developing strategies to optimize fistula maturation. Studies have revealed that the presence of stenoses and accessory draining veins may contribute to unsuccessful fistula maturation. Endovascular treatment, including balloon angioplasty and accessory vein embolization, aim to correct anatomical factors that negatively affect the maturation process. This article reviews the techniques and outcomes of endovascular treatment in the management of immature fistulas.

Transradial access for balloon-assisted maturation of arteriovenous fistulas

Balloon-assisted maturation (BAM) of arteriovenous fistulas has conventionally been performed via direct fistula access. The transradial approach has not been well described for BAM, although its use has been reported throughout the cardiology literature. The purpose of the present study was to assess the outcomes of transradial access for its use with BAM. A retrospective review of 205 patients with transradial access for BAM was performed. One sheath was inserted into the radial artery distal to the anastomosis. We have described the procedural details, complications, and outcomes. The procedure was considered technically successful if transradial access had been established and the AVF had been ballooned with at least one balloon without major complications. The procedure was considered clinically successful if no further interventions had been required for AVF maturation. The average time for BAM via transradial access was 35 ± 20 minutes, with 31 ± 17 mL of contrast used. No access-related perioperative complications, including access site hematoma, symptomatic radial artery occlusion, or fistula thrombosis, had occurred. The technical success rate was 100%, and the rate of clinical success was 78%, with 45 patients requiring additional procedures to achieve maturation. Transradial access is an efficient alternative to trans-fistula access for BAM. It is technically easier and allows for better visualization of the anastomosis.

The Retrograde Basilic Approach for Balloon-Assisted Maturation of Brachiocephalic Arteriovenous Fistulas

PURPOSE

To assess the feasibility and outcomes of an approach utilizing transbasilic access for balloon-assisted maturation (BAM) of brachiocephalic arteriovenous fistulas (BCAVF).

MATERIALS AND METHODS

This retrospective analysis comprised 28 patients (mean age 63 years ± 10.8) who underwent endovascular treatment of their immature BCAVFs via a basilic approach from December 2016 to December 2018. The mean age of the BCAVF was 3.3 months ± 1.4 at time of BAM. Other demographic data, vascular access characteristics, procedural data, technical and clinical success rates and adverse events were also evaluated.

RESULTS

All patients had inflow juxta-anastomotic stenoses, with 4 patients (14%) having concomitant outflow tract stenoses, and 1 patient (4%) having a short segment occlusion at the stenotic juxta-anastomotic segment. Technical success was achieved in 27 patients (96%). The mean diameter of the largest balloon used was 5.7mm ± 0.6. Clinical success was achieved in 22 patients (79%), with 6 patients (21%) requiring a subsequent additional intervention before successful cannulation. No perioperative adverse events were observed.

CONCLUSION

The retrograde basilic approach is feasible, safe and effective for balloon-assisted maturation of BCAVFs.

Clinical Efficacy of the Transradial Approach in Percutaneous Intervention for a Malfunctioning Arteriovenous Fistula

Purpose

To evaluate the effectiveness of the transradial artery approach (TRA) for treating malfunctioning arteriovenous fistulas (AVFs) in patients on hemodialysis.

Materials and Methods

A retrospective analysis was conducted in this single-center study of TRA endovascular procedures in 73 patients (43 male and 30 female; mean age of 67.4 years (range, 42–92 years) with malfunctioning AVFs, between January 2008 and April 2019. Patients’ baseline and lesion characteristics, technical and clinical success, and complications were evaluated, and functional patency was analyzed using the Kaplan-Meier method.

Results

Radial artery approaches were successful in all patients. Angioplasty performed using the TRA achieved technical and clinical success rates of 98.6%(72/73) and 91.7%(67/73), respectively. The median primary patency time was 18.8 ± 15.9 months. The primary functional patency rates at 3, 6, and 12 months were 82.1%, 68.6%, and 63.9%, respectively. There were no major complications or adverse events, such as hand ischemia, related to the radial artery approach.

Conclusion

In selected cases, the TRA can be used complementary to the transvenous approach to treat malfunctioning AVFs.

Navigation of a Dormant AV Fistula for PCI in a Patient With High-Risk NSTEMI

Arteriovenous (AV) fistulae for hemodialysis in patients with end-stage renal disease usually prevents ipsilateral transradial access (TRA) for coronary angiography. We present a case of coronary angiography and percutaneous coronary intervention via left TRA with navigation through a dormant AV fistula in a patient with limited vascular access. (Level of Difficulty: Intermediate.).

Transradial access for arteriovenous fistuloplasty in Singapore

BACKGROUND

Endovascular balloon angioplasty is standard therapy for dysfunctional arteriovenous fistula in end-stage renal failure patients on hemodialysis. Venous antegrade or retrograde puncture of the fistula is typically performed to gain access for fistuloplasty. Transradial approach for brachiocephalic or brachiobasilic arteriovenous fistulas offers an alternative method of access with the advantage of addressing multi-focal juxta-anastomotic and venous stenosis from the same approach. We aim to review the efficacy, outcomes and complication rates of transradial access for arteriovenous fistuloplasty among patients in Singapore.

METHODS

A retrospective review of 195 endovascular fistuloplasties from September 2017 to August 2019, at a tertiary university hospital Vascular Surgery unit.

RESULTS

Of 195 fistuloplasties, 43 (22%) were transradial approach (23 brachiocephalic arteriovenous fistulas, 20 brachiobasilic arteriovenous fistulas) in 33 patients (67% male and mean age = 65 years). Of these 43 procedures, 11 (26%) were performed as balloon-assisted maturation fistuloplasties while 32 (74%) were performed for mature arteriovenous fistulas with multi-focal juxta-anastomosis and venous stenosis. Technical success rate was 95% with mean procedure duration at 43.5 ± 14.6 min. Mean pre- and post-fistuloplasty dialysis access flow rates increased from 502 to 952 ml/min (p < 0.001). Post-intervention primary patency was 100%, 66% and 20% at 1, 6 and 12 months, respectively. There were four patients with non-limb-threatening radial artery thrombosis (9.3%) while there was no radial artery pseudoaneurysm or post-procedural bleeding.

CONCLUSION

Transradial approach for arteriovenous fistuloplasty is a safe and feasible option in patients requiring balloon-assisted maturation or with multi-focal juxta-anastomotic and venous stenosis.

Snuff box radial artery access for arteriovenous fistula intervention

PURPOSE

The aim of this article is to retrospectively compare snuff box radial artery access with direct fistula access for radiocephalic fistula intervention.

MATERIALS AND METHODS

Review of 68 consecutive radiocephalic interventions between April 2013 and April 2017 was performed. The snuff box radial access was performed under ultrasound guidance with the hand in a neutral position (thumb up). The snuff box radial artery was entered distal to the extensor pollicis longus, over the trapezium bone. Hand held pressure was applied for hemostasis. The procedure times, success, and complications of snuff box radial artery access procedures were reviewed.

RESULTS

Snuff box radial artery access was used in 25% (17/68) of radiocephalic fistula interventions. All access procedures were successful. Snuff box radial artery access was only used in cases involving the proximal fistula. Lesions treated from snuff box radial artery access approach included 19% (10/54) of fistula stenosis, 50% (1/2) thrombosis, 63% (5/8) immature fistulae, 100% (1/1) steal syndrome, and none of the (0/5) symptomatic outflow occlusions. The mean procedure times for snuff box radial artery access and direct fistula access were not significant at 29.1 ± 16.3 min (range = 10-81) and 26.8 ± 14.0 min (range = 5-70), respectively (p < 0.57). Minor hematoma occurred in 12% (2/17) snuff box radial artery access and 2% (1/51) direct fistula access. There were no major complications.

CONCLUSION

Snuff box radial access was used successfully for radiocephalic fistula intervention with procedure times similar to direct fistula access without major complications.

Below-the-elbow intervention for Buerger's disease

An increasing attention has been paid to endovascular therapy for lower limb ischemia in patients with Buerger's disease. However, critical hand ischemia in Buerger's disease patients has been underappreciated despite a tremendous advancement of endovascular therapy for peripheral arterial disease. Herein, we describe endovascular "hand" salvage with a below-the-elbow intervention.

Ipsilateral jugular access to treat an otherwise inaccessible puncture-related arteriovenous fistula pseudoaneurysm: a technical note

BACKGROUND

The standard approach for the endovascular treatment of a dysfunctional or occluded hemodialysis access in the upper limbs includes a direct intervention through the access itself or alternatively, when not feasible, through the brachial or radial artery access. Nonetheless, there are certain circumstances in which these approaches are not easily achieved.

METHODS

An 89-year-old male with end-stage renal disease developed a pseudoaneurysm after an hemorrhagic complication of a recently transposed native basilic arteriovenous fistula secondary to a needle puncture. Dehiscence of the injured access with spontaneous arterial bleeding evolved as a consequence of the upper limb swelling, rendering therapeutic intervention of the access through a conventional route impossible. A fistulogram through puncture of the common femoral artery was performed to obtain an accurate diagnosis. However, this approach was insufficient to advance the covered stent with the intention of excluding the pseudoaneurysm, as the stent delivery system could not reach the desired site. Given that the covered stent insertion required a 9 Fr introducer, the radial artery approach was ruled out. Therefore, we chose a venous access via the ipsilateral internal jugular vein, which was punctured under ultrasound guidance.

RESULTS

This strategy was useful to advance the stent and exclude the pseudoaneurysm successfully.

CONCLUSIONS

This technique should be considered for those individuals in whom conventional routes of approach for repairing dialysis accesses are not feasible or are extremely risky.

Radial artery approach to salvage nonmaturing radiocephalic arteriovenous fistulas

PURPOSE

To evaluate the usefulness of an approach through the radial artery distal to the arteriovenous anastomosis for salvaging nonmaturing radiocephalic arteriovenous fistulas.

METHODS

Procedures that fulfilled the following criteria were retrospectively reviewed: (1) autogenous radiocephalic fistulas, (2) fistulas less than 3 months old, (3) distal radial artery approach for salvage. From 2005 to 2011, a total of 51 patients fulfilling the above criteria were enrolled. Outcome variables were obtained from angiographic, clinical and hemodialysis records, including the success, complication, and primary and secondary patency rates.

RESULTS

The overall anatomical and clinical success rates for the distal radial artery approach were 96 and 94%, respectively. The average procedure time was 36 ± 19 min. Six patients (12%) experienced minor complications as a result of extravasations. No arterial complication or puncture site complication was noted. The postinterventional 6-month primary patency rate was 51%, and the 6-month secondary patency rate was 90%. When the patients were divided into a stenosed group (20 patients) and an occluded group (31 patients), there were no differences in the success rate, complication rate, or primary and secondary patency rates.

CONCLUSION

An approach through the radial artery distal to the arteriovenous anastomosis is an effective and safe alternative for the salvage of nonmaturing radiocephalic arteriovenous fistulas, even for occluded fistulas.

Transradial approach for cardiovascular interventions and its implications for hemodialysis vascular access

Because of its advantages, the transradial approach for cardiovascular interventions has gained significant popularity. However, this approach can be associated with radial artery thrombosis and occlusion. The complication generates a major concern for its potential impact on the future creation of an arteriovenous hemodialysis access. The issue gains more importance as a significant number of patients with cardiovascular disease suffer from underlying chronic kidney disease (CKD) and might need an arteriovenous access for hemodialysis therapy. In this context, the preservation of the arterial system is of equal importance to the frequently highlighted venous conservation for the successful creation of an arteriovenous access. It is for this reason that the Fistula First Breakthrough Initiative recommends avoiding the use of the radial artery for performing percutaneous interventions in patients with advanced CKD. Furthermore, there is scarce clinical data and publication regarding the impact of transradial approach on hemodialysis access. Is it possible to utilize the potential benefits and minimize the potential risks of transradial approach in chronic kidney disease patients? On the basis of current knowledge, this review discusses related issues of transradial approach to raise awareness and understanding, which are essential to proper caring of CKD patients undergoing cardiovascular interventions.

Percutaneous transluminal angioplasty for radial-cephalic fistulae with stenosis at the arteriovenous junction

INTRODUCTION

The aim of this study was to analyze the predictive factors for initial success and long-term patency of percutaneous transluminal angioplasty for radial-cephalic (RC) fistulae with stenosis at the arteriovenous junction (AVJ). Stenosis at the AVJ of RC fistulae involves both the feeding artery and drainage vein and is similar to a bifurcation lesion, which carries a worse outcome. The optimal intervention method for this type of lesion is currently unknown.

METHODS

Ninety-one percutaneous transluminal angioplasty procedures for stenosis at the AVJ of RC fistulae were reviewed retrospectively. Parameters including age, sex, location of the RC fistula (right or left arm), approach site (radial artery or cephalic vein) and involvement of proximal radial artery (PRA) dilatation were analyzed for initial procedure success and long-term patency rates.

RESULTS

The total initial success rate was 94.5%. The existence of total occlusion was recognized as the only factor significantly associated with a high procedural failure rate (39% versus 0%, P < 0.001). For long-term patency rate, the only significant factor was the involvement of PRA dilatation (P = 0.026 by Cox-Mantel and 0.03 by generalized Wilcoxon methods). The 6-month, 1-year and 18-month patency rates were 64%, 45.3% and 20.9%, respectively, for all procedures, and 70.7% versus 57.8%, 56.1% versus 35.6% and 36.6% versus 6.7% for procedures with and without PRA dilatation, respectively.

CONCLUSIONS

In treating stenosis at the AVJ of RC fistulae, while initial procedural failure occurred mainly in occluded lesions, involvement of PRA dilatation was the only significant predictive factor associated with long-term patency.

Radial arterial approach with adjunctive urokinase for treating occluded autogenous radial-cephalic fistulas

There are no data regarding the feasibility and safety of a radial arterial approach with adjunctive urokinase for treating occluded autogenous radial-cephalic fistulas. We retrospectively examined 54 transradial interventions performed to treat occluded autogenous radial-cephalic fistulas within 72 h of occurrence. Urokinase was used in patients with a large thrombus burden. A total of 92 lesions in 54 consecutive patients (27 males, 27 females; mean age, 61.8+/-12.3 years) were treated via radial access. All radial punctures were successful except in one patient. Most thrombotic lesions were located within 1 cm of the radiocephalic anastomosis (79.6%). The mean length of treated thrombotic lesions was 10.3+/-5.4 cm (range, 4-32 cm). Twenty-five patients (46.3%) received urokinase (mean dose, 96,000+/-30,000 U). After transradial intervention, systolic, diastolic, and mean pressures in the radial artery decreased from 179+/-41, 77+/-17, and 111+/-22 mm Hg to 71+/-29, 36+/-15, and 48+/-19 mm Hg (all p's\0.001), respectively. Four radial interventions were unsuccessful. The anatomic and clinical success rates of the radial approach were both 92.6%; postinterventional primary patency rates were 65% at 6 months and 40% at 12 months. Two minor vascular complications were noted, one caused by guidewire-induced contrast extravasation and the other by balloon-induced contrast extravasation. No patient developed clinical signs of pulmonary embolism. In conclusion, the radial approach with adjunctive urokinase is an effective and safe approach to treat occluded autogenous radial-cephalic fistulas.

Feasibility of trans-radial approach in percutaneous intervention for upper arm dialysis access

BACKGROUND

This retrospective study evaluated the feasibility and efficacy of trans-radial intervention for upper arm dialysis access.

METHODS

This study retrospectively reviewed 165 trans-radial interventions performed for upper arm dialysis access in 101 patients. Sixty-nine patients had arteriovenous graft (AVG), and 32 had arteriovenous fistula (AVF). Balloon angioplasty was performed in 66 stenotic dialysis accesses and 99 thrombosed dialysis accesses. Thrombosed dialysis access was further managed by additional balloon thrombectomy with or without urokinase injection.

RESULTS

Procedural time was 46.7 +/- 25.5 minutes. Anatomic and clinical success rates were 89.7% and 84.2%, respectively. The rate of complications, most of which involved lesion rupture with contrast-media extravasation and distal embolism, was 9.7%. Pretreatment stenosis was more severe (p = 0.01) and the prevalence of total occlusion was higher (p < 0.01) in the AVG group than the AVF group. The success rate and complication rate did not statistically differ (p = 0.59). Additionally, the thrombosed group had a lower success rate (p = 0.02), a higher complication rate (p < 0.01) and a longer procedural time (p < 0.01) than the stenotic group.

CONCLUSIONS

Comparison with previous studies employing the traditional approach reveals that trans-radial intervention has a comparable success rate, procedural time and complication rate for upper arm dialysis access. Therefore, trans-radial intervention is a safe and feasible technique for upper arm dialysis access.

Bidirectional angioplasty with single vascular access in autogenous arteriovenous fistula

PURPOSE

In autogenous arteriovenous (AV) fistulas with multiple stenoses at extreme ends, one option for treatment of the stenoses with angioplasty is dual access directed toward both ends of the fistula. The present study is a retrospective evaluation of experiences with an alternative access technique, bidirectional angioplasty with a single vascular access.

MATERIALS AND METHODS

A total of 124 bidirectional angioplasty procedures with a single vascular access performed in 96 autogenous AV fistulas (48 men and 48 women; mean age, 58 years) were evaluated. After fistulography, a dilated segment of the draining vein located between the proximal and distal stenoses, with its course straight or convex toward the interventional radiologist, was punctured with an 18-gauge needle. The needle was directed antegrade and an introducer sheath was inserted for angioplasty of the proximal or central venous stenoses. Then, with a safety guide wire in place, the introducer sheath was withdrawn and redirected retrograde for angioplasty of the distal stenoses.

RESULTS

Technical success rates of redirection of the introducer sheath and angioplasty were 100% and 96.8%, respectively. The failures of angioplasty were related to elastic recoil (n = 3) and inability to pass the guide wire through an occluded distal vein (n = 1). Overall procedure times were 7-70 minutes (mean, 31 min). One pseudoaneurysm was the only access-related complication.

CONCLUSIONS

Bidirectional angioplasty with a single vascular access is a feasible method of access in angioplasty of autogenous AV fistulas with stenoses at extreme ends.