Application of the AMPLATZER Vascular Plug in Endovascular Occlusion of Dialysis Accesses

Rapid progression of finger gangrene in a hemodialysis patient: A case report

Severe hemodialysis access-induced distal ischemia is an uncommon complication after arteriovenous fistula creation. Finger amputation is rare and generally does not involve the entirety of the digit. The distal revascularization interval ligation procedure has become less commonly used for hemodialysis access-induced distal ischemia over the past decade. The procedure typically requires general anesthesia, greater saphenous vein harvest, and brachial artery ligation. We describe a 64-year-old female with hypertension, diabetes mellitus, and end-stage renal disease on hemodialysis via a well-functioning brachiocephalic arteriovenous fistula who developed rapid progression of finger gangrene. She underwent the distal revascularization interval ligation procedure, followed by finger amputations. The finger amputations healed within 6 months of the distal revascularization interval ligation procedure and the fistula was preserved at 2-year follow-up.

Dialysis Access-Associated Steal Syndrome and Management

Dialysis-associated steal syndrome (DASS) occurs in 1-8% of hemodialysis patients with arteriovenous (AV) access. Major risk factors include use of the brachial artery for access creation, female sex, diabetes, and age > 60 years. DASS carries severe patient morbidity including tissue or limb loss if not recognized and managed promptly, as well as increased mortality. Diagnosis of DASS requires a directed history and physical exam supported by non-invasive testing. Prior to definitive therapy, detailed arteriography, fistulography, and flow measurements are performed to delineate underlying etiologies and guide management. To optimize success, DASS treatment should be individualized according to access location, underlying vascular disease, flow dynamics, and provider expertise. Possible causes of DASS include extremity inflow or outflow arterial occlusive disease, high AV access flow rate, and reversal of distal extremity arterial blood flow; DASS may also exist without any of the prior features. Depending on the DASS etiology, various endovascular and/or surgical interventions should be considered. Regardless, in the majority of patients presenting with DASS, access preservation can be achieved.

Endovascular Embolization in Problematic Hemodialysis Arteriovenous Fistulas: A Nonsurgical Technique

Introduction:

In the past, surgical techniques were considered gold standard practice for obliterating the accessory veins, reducing the flow across the high flowing arteriovenous fistulas (AVFs), or for closing the problematic hemodialysis AVFs. However, recently endovascular embolization has emerged as a safe and cost-effective alternative to these surgical techniques. In this study, technical and clinical success, and safety of endovascular embolization have been evaluated for accessory vein obliteration, flow reduction, and fistula closure in problematic AVFs using various embolizing agents.

Methods:

This is a retrospective study of patients with problematic hemodialysis AVFs, who underwent endovascular embolization for accessory vein obliteration, flow reduction, and AVF closure at our center from February 2017 to January 2019 with various embolic agents like vascular plugs (VP), thrombin, coils, and glue. Follow-up was done at 1 week, 3 months, 6 months, and annually thereafter.

Results:

In this study 30 patients with problematic hemodialysis AVFs [Left brachiocephalic fistula (BCF) (n = 22), right BCF (n = 4), and left radiocephalic fistula (RCF) (n = 4)], underwent endovascular embolization for accessory vein obliteration (n = 6), flow reduction (n = 3), and AVF closure (n = 21). Of the 6 patients undergoing embolization for obliteration of accessory collateral, 4 patients had nonmaturing AVFs and 2 patients had symptoms of venous hypertension (VH). Post embolization, all 4 AVFs matured over a month and symptoms of VH completely resolved within a week. Three patients who underwent embolization for flow reduction had patent AVF (on doppler) post procedure and they achieved adequate flow during dialysis with complete resolution of symptoms of VH. Out of 21 patients, who underwent endovascular closure, complete AVF thrombosis was seen in 18 patients only with the use of VP, while 4 patients required additional procedure to achieve complete thrombosis of AVF.

Conclusion:

Endovascular embolization in problematic hemodialysis AVF is a safe and cost-effective alternative to open surgical methods and vascular plug could be embolic agent of choice for AVF closure.

Intraplug coils delivery for fast closure of giant arteriovenous fistulas (AVFs) aneurysm in dialyzed patient

Aneurysm of arteriovenous fistulas (AVFs) created for hemodialysis, could be related with several complications including steal syndrome and cardiac abnormalities, requiring thus a fast closure. Considering the high comorbidity of surgical closure, percutaneous endovascular occlusion could be considered as effective and safe treatment. A 58-year-old white male with AVF aneurysm was treated endovascularly, using a combined approach with Amplatzer Vascular Plug II (AVP II) and intraplug coils delivery pricking directly and percutaneously the plug with a 20 G spinal-needle to obtain a fast closure and improving AVP thrombogenicity. To avoid the risk of migration due to the large diameter of these aneurysm, AVP was deployed at the narrowest point of AVFs, exploiting the maximum diameter of the plug using arteriography and fistulography. Patient described quick improvement of initial symptoms and during the follow-up a complete remission of initial symptoms, and no cases of plug migration were observed. There were no late complications related to insertion of the AVP with the coils. Our case report suggests that the endovascular approach is a feasible and safe technique also for the treatment of AVFs giant aneurysm which requires urgent treatment when open surgery is contraindicated.

Hemodialysis Arteriovenous Access Occlusion Using the Amplatzer Vascular Plug in Patients with Intractable Arm Edema

Objectives

Vascular occlusion of hemodialysis arteriovenous access (AVA) using an Amplatzer vascular plug (AVP; St. Jude Medical, St. Paul, MN, USA) is an arising and alternative practice in selected patients; however, few reported cases can be found in the literature. Herein, we report on our experience with endovascular treatment of complicated AVA.

Materials and Methods

From September 2015 to December 2016, 3 patients at our clinic underwent an occlusion of hemodialysis AVA with 2 different Amplatzer vascular plugs: 2 patients with type II and 1 patient with type IV. Of these, 1 patient was treated for an autologous radiocephalic fistula, the second patient was treated for an autologous brachiocephalic fistula located at the elbow, and the third was, instead, treated for a radiocephalic forearm fistula. The reason for closing the AVA in all patients was due to the presence of dialysis-associated steal syndrome with critical hand ischemia and intractable ipsilateral edema.

Results

All AVAs were treated using an AVP. No plug migration, access revascularization, persistent ischemia, nor other complications were observed.

Conclusion

This report suggests that the use of AVP for embolization of complicated AVA is a safe and reasonable alternative to open surgery in selected patients.

Amplatzer vascular plug as an embolic agent in different vascular pathologies: A pictorial essay

The Amplatzer Vascular Plug (AVP) is a cylindrical plug made of self-expanding nitinol wire mesh with precise delivery control, which can be used for a variety of vascular pathologies. An AVP is an ideal vascular occlusion device particularly in high-flow vessels, where there is high risk of migration and systemic embolization with traditional occlusion devices. We performed 28 embolizations using the AVP from 2009 to 2014 and achieved complete occlusion without complications.

Use of the Amplatzer Type 2 Plug for Flow Redirection in Failing Autogenous Hemodialysis Fistulae

PURPOSE

To present our experience with redirecting the outflow of mature arteriovenous fistulae (AVFs) in patients with cannulation and/or suboptimal flow problems by percutaneous intervention using the Amplatzer Vascular Plug II (AVP II).

METHODS

We retrospectively reviewed patients who presented with difficulty in cannulation and/or suboptimal flow in the puncture zone of the AVF and who underwent intervention using the AVP II to redirect the outflow through a better cannulation zone from March 2009 to November 2012. The mean survival rate of all AVFs was estimated, and the effects of patient age, sex, and AVF age on the AVF survival time were determined.

RESULTS

In total, 31 patients (17 male and 14 female) with a mean age of 57.8 years (range, 20-79 years) were included. In 2 patients, the AVF failed within the first 15 days because of rapid thrombosis. In 9 patients, the new AVF route was working effectively until unsalvageable thrombosis developed. One of the 31 patients died 9 months before the last radiologic evaluation. The new AVF route was still being used for dialysis in the remaining 19 patients. The mean AVF survival rate was 1,061.4 ± 139.4 days (range, 788-1,334 days). Patient age, sex, and AVF age did not affect the survival time.

CONCLUSION

We suggest that the AVP II is useful for redirecting the outflow of AVFs with cannulation problems and suboptimal flow. Patency of existing AVFs may be extended, thereby extending surgery-free or catheter intervention-free survival period.