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Battistella A, Linger M, Nguyen AT, Madukwe D, Roy-Chaudhury P, Tan W. Rebuilding vascular access: from the viewpoint of mechanics and materials. Front Bioeng Biotechnol 2024; 12:1448186. [PMID: 39295847 PMCID: PMC11409097 DOI: 10.3389/fbioe.2024.1448186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 08/22/2024] [Indexed: 09/21/2024] Open
Abstract
This review presents a comprehensive analysis of vascular access in hemodialysis, focusing on the current modalities, their associated challenges, and recent technological advancements. It closely examines the status of three primary types of vascular access: arteriovenous fistulas, arteriovenous grafts, and central venous catheters. The review delves into the complications and pathologies associated with these access types, emphasizing the mechanobiology-related pathogenesis of arteriovenous access. Furthermore, it explores recent clinical trials, biomaterials, and device innovations, highlighting novel pharmaceutical approaches, advanced materials, device designs, and cutting-edge technologies aimed at enhancing the efficacy, safety, and longevity of vascular access in hemodialysis. This synthesis of current knowledge and emerging trends underscores the dynamic evolution of vascular access strategies and their critical role in improving patient care in hemodialysis.
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Affiliation(s)
- Aurora Battistella
- Paul M. Rady Mechanical Engineering, University of Colorado at Boulder, Boulder, CO, United States
| | - Morgan Linger
- Paul M. Rady Mechanical Engineering, University of Colorado at Boulder, Boulder, CO, United States
- Department of Biomedical Engineering, University of Colorado at Boulder, Boulder, CO, United States
| | - Anh Thy Nguyen
- Paul M. Rady Mechanical Engineering, University of Colorado at Boulder, Boulder, CO, United States
| | - David Madukwe
- Paul M. Rady Mechanical Engineering, University of Colorado at Boulder, Boulder, CO, United States
| | - Prabir Roy-Chaudhury
- Department of Medicine, University of North Carolina Kidney Center, Chapel Hill, NC, United States
- WG (Bill) Hefner VA Medical Center, Salisbury, NC, United States
| | - Wei Tan
- Paul M. Rady Mechanical Engineering, University of Colorado at Boulder, Boulder, CO, United States
- Department of Biomedical Engineering, University of Colorado at Boulder, Boulder, CO, United States
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Bond RG, Arasu R, Jantzen TM, Alley RP. Patency rates following treatment with the WRAPSODY™ Cell-Impermeable Endoprosthesis for recalcitrant renal access circuit dysfunction: Results from a tertiary Australian centre. Vascular 2024:17085381241273147. [PMID: 39132802 DOI: 10.1177/17085381241273147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
OBJECTIVE To describe clinical outcomes associated with the use of the WRAPSODY Cell-Impermeable Endoprosthesis at a tertiary center in Western Australia. METHODS Patients with recalcitrant occlusive disease in the venous outflow of their arteriovenous access circuits were treated with WRAPSODY. Patients were prospectively followed up to 12-month post-procedure. Study measures included 30-day adverse events, technical success, target lesion primary patency, access circuit primary patency, and assisted access circuit primary patency. RESULTS Twenty-seven WRAPSODY devices were used to treat 15 consecutive patients. The technical success rate was 100%. No device-related adverse events were observed during the follow-up period. Two patients did not complete the full follow up. Patency rates at 3-, 6-, and 12 months for target lesion primary patency were 100% (15/15), 100% (15/15), and 100% (13/13), respectively. Rates for access circuit primary patency at 3-, 6-, and 12 months were 73.3% (11/15), 46.7 % (7/15), and 46.2% (6/13), respectively. Edge stenosis was observed in 33.3% (5/15) of cases and accounted for 5 of the 8 patients who experienced failed access circuit primary patency on angiogram. Primary assisted functional patency was 100% at 12 months. CONCLUSION WRAPSODY can be utilized safely and has durable patency in real-world patients with complex anatomical renal access stenotic lesions. The therapeutic benefits associated with the device may encourage broader use in clinical practice.
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Affiliation(s)
- Richard G Bond
- Department of Vascular Surgery, Fiona Stanley Hospital, Perth, WA, USA
| | - Rohan Arasu
- Department of Vascular Surgery, Fiona Stanley Hospital, Perth, WA, USA
| | - Troy M Jantzen
- Territory management department, Merit Medical Australia Pty Ltd, Braeside, VIC, Australia
| | - Richard P Alley
- Marketing Department, Merit Medical Systems, Inc, South Jordan, UT, USA
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Stove C, Kingsmore DB, Stevenson KS, Thomson PC, Nath A, Kasthuri R. The impact of stent-graft sizing on venous stenosis re-intervention and arteriovenous graft patency: Free-floating stent outflow is associated with improved outcomes. J Vasc Access 2024; 25:834-842. [PMID: 36428293 DOI: 10.1177/11297298221137152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Early cannulation arteriovenous grafts (ecAVG) for dialysis access are limited by reintervention for venous stenosis (VS) despite their good initial patency. Whilst stent-grafts (SG) have shown promise, the optimal sizing is unclear. Therefore, this study aims to determine if outflow vein diameter, SG diameter or these relative to each other (V:Sr) alters outcomes, and if so, which is more important. METHODS Retrospective analysis was performed of Gore® Acuseal® ecAVGs with VS treated with Gore® Viabahn® SG over a 7-year period. Primary patency (PP), time to thrombosis and functional patency were analysed by SG length/diameter, vein diameter and V:Sr. RESULTS We identified 114 ecAVGs with median follow-up 492 days (IQR 189-770). SG length and diameter did not correlate with PP, however, there was a significant relationship between vein diameter and PP (RR = 0.901 (0.832-0.975), p = 0.01) and between V:Sr and PP (RR = 0.462 (0.255-0.838), x2 = 5.866, p = 0.0015). The optimal V:Sr was ⩾1.4 (i.e. vein diameter at least 40% greater than the stent-graft; or 'free-floating' stent outflow) (RR = 2.759 (1.670-4.558), p < 0.001), translating to a difference in median PP of 252 versus 496 days (IQR: 188-316; 322-670). On multivariate analysis, absolute vein diameter lost significance, whilst V:Sr remained an independently significant predictor of PP (RR = 3.247 (1.560-6.759), p = 0.02). CONCLUSIONS Placement of the SG outflow into a relatively larger segment of vein was associated with a significant increase in PP independent of the absolute vein diameter. This suggests that larger calibre SG which are apposed to the vein wall are not required for optimal primary patency, and indeed should be actively avoided. Instead, a 'free-floating' stent outflow which is undersized relative to the recipient vein (whilst maintaining a minimum anchoring calibre) is recommended where possible. This should be considered during intervention and may require selection of longer devices, where practical, to bring the stent outflow into a larger vein segment. LEVEL OF EVIDENCE Level 3a, Non-randomised controlled cohort/follow-up study.
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Affiliation(s)
- Callum Stove
- Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - David B Kingsmore
- Vascular and Endovascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Karen S Stevenson
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Peter C Thomson
- Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Alex Nath
- Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Ram Kasthuri
- Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
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Harduin LDO, Barroso TA, Guerra JB, Filippo MG, de Almeida LC, Vieira BR, Mello RS, Galhardo AM, Castro-Santos GD, Virgini-Magalhães CE, Strogoff-de-Matos JP. Safety and efficacy of a new covered stent in hemodialysis vascular access outflow stenosis: A Brazilian multicenter retrospective study. J Vasc Access 2024:11297298231226259. [PMID: 38316624 DOI: 10.1177/11297298231226259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Vascular stenosis commonly leads to dysfunction in hemodialysis vascular access. Although percutaneous transluminal angioplasty is an established treatment, stent utilization has increased in the last decade as an alternative solution to extend the access function. This study evaluated the safety and initial results of a new impermeable covered stent for treating vascular access outflow stenosis. METHODS Investigators retrospectively analyzed 114 hemodialysis patients treated with polytetrafluorethylene-covered stents from September 2018 to September 2022 across four centers. Lesions treated were de novo or restenotic and located in the venous graft anastomosis, outflow segment, cephalic arch, and basilic swing point. Patients were followed by in-person physical examination at 1, 3, and 6 months, and Duplex ultrasound was performed to evaluate the vascular access circuit and in-stent restenosis. The primary efficacy endpoint was target lesion primary patency at 1, 3, and 6 months. Secondary endpoints included access circuit primary patency and secondary patency at 1, 3, and 6 months. The primary safety endpoint was freedom from local or systemic serious adverse events through 30 days post-procedure. RESULTS Forty-four patients had thrombosed access at the initial presentation, and 41 patients presented with recurrent stenosis. The target lesion primary patency rates at 1, 3, and 6 months were 100%, 89.4%, and 74%, respectively. The access circuit primary patency rates were 100% at 1 month, 85% at 3 months, and 62.7% at 6 months. The secondary patency rates at 1, 3, and 6 months were 100%, 96.4%, and 94.6%, respectively. In the adjusted multivariate Cox regression analysis, only recurrent lesions and female gender were associated with reduced primary patency rates. No serious adverse event was observed through the first 30 days post-procedure. CONCLUSION In this retrospective analysis, a new covered stent was shown to be safe and effective for treating peripheral outflow stenosis in vascular access.
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Affiliation(s)
| | | | - Julia Bandeira Guerra
- Image Department, Hospital Niterói Dor and Centro Clínico LIVCARE, Niterói (Rio de Janeiro), Brazil
| | - Márcio Gomes Filippo
- Vascular Surgery Service, Hospital Universitário Clementino Fraga Filho (HUCFF), Universidade Federal do Estado do Rio de Janeiro (UFRJ), Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Brunno Ribeiro Vieira
- Instituto Nacional de Traumatologia e Ortopedia, Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | | | - Carlos Eduardo Virgini-Magalhães
- Vascular and Endovascular Surgery Department, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
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Rajan DK, Kitrou PM. Prospective, Multicenter, Observational Study to Evaluate a Cell-Impermeable Endoprosthesis for Treatment of Stenosis or Occlusion within the Dialysis Outflow Circuit of an Arteriovenous (AV) Fistula or AV Graft (The WRAP Registry). Cardiovasc Intervent Radiol 2023; 46:1285-1291. [PMID: 37592020 PMCID: PMC10533592 DOI: 10.1007/s00270-023-03531-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/29/2023] [Indexed: 08/19/2023]
Abstract
PURPOSE Dysfunctional vascular access due to stenosis/occlusion within the arteriovenous fistula or graft (AVF/AVG) negatively affects the clinical management of patients undergoing hemodialysis. Results from the feasibility study of the WRAPSODY™ Cell-Impermeable Endoprosthesis demonstrated that the device can achieve high patency rates and maintain integrity of the dialysis outflow circuit. This study was designed to assess real-world evidence of safety and efficacy outcomes following device placement. MATERIALS AND METHODS This is a prospective, multicenter, non-investigational, post-market observational study of 500 patients at up to 50 centers worldwide with a mature AVF/AVG dialysis access (≥ 1 hemodialysis session) who experience stenosis/occlusion of the outflow circuit prior to placement of WRAPSODY. Patients will be divided into the following two cohorts: peripheral or central thoracic. Primary outcome measures include target lesion primary patency (TLPP) at 6 months and procedure and/or device-related events through 30 days post-procedure. Secondary outcome measures include TLPP, safety events, and the number of interventions needed to maintain patency through the 24 month study period. Exploratory endpoints include time to access abandonment, resumption of successful dialysis, functional patency, and pending available imaging data, any incidence of stent fractures, migration, or edge stenosis. Study enrollment began in June 2022, the last patient visit is expected in 2026. DISCUSSION It is expected that this study will provide real-world evidence regarding the performance of the WRAPSODY device in a diverse population of patients, which may encourage its use in the continuum of hemodialysis access management. TRIAL REGISTRATION NCT05062291.
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Affiliation(s)
- Dheeraj K Rajan
- Department of Medical Imaging, University Medical Imaging Toronto/University of Toronto, University Health Network, 585 University Avenue, 1-PMB-287, Toronto, ON, M5G 2N2, Canada.
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Haskal ZJ, Dolmatch BL. Hemodialysis Access Stent Graft Trials: Past, Present, and Future. Cardiovasc Intervent Radiol 2023; 46:1154-1161. [PMID: 36941431 DOI: 10.1007/s00270-023-03389-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/07/2023] [Indexed: 03/23/2023]
Affiliation(s)
- Ziv J Haskal
- School of Medicine, University of Virginia, Charlottesville, USA.
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Gilbert J, Rai J, Kingsmore D, Skousen J, Ptohis N. First Clinical Results of the Merit WRAPSODY™ Cell-Impermeable Endoprosthesis for Treatment of Access Circuit Stenosis in Haemodialysis Patients. Cardiovasc Intervent Radiol 2021; 44:1916-1917. [PMID: 34755199 PMCID: PMC8626388 DOI: 10.1007/s00270-021-03001-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 10/31/2022]
Affiliation(s)
- James Gilbert
- Oxford Transplant Centre, Oxford University Hospitals NHS Foundation Trust, Old Road, Headington, OX3 7LE Oxford UK
| | - Jason Rai
- Oxford Transplant Centre, Oxford University Hospitals NHS Foundation Trust, Old Road, Headington, OX3 7LE Oxford UK
| | | | - John Skousen
- Merit Medical Systems, Inc, South Jordan, Utah USA
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Bream PR, Chick JFB, Lessne ML. Letter to the Editor Regarding "First Clinical Results of the Merit WRAPSODY Cell-Impermeable Endoprosthesis for Treatment of Access Circuit Stenosis in Haemodialysis Patients" published by Gilbert et al. Cardiovasc Intervent Radiol 2021; 44:1914-1915. [PMID: 34708265 DOI: 10.1007/s00270-021-02988-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/08/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Peter R Bream
- Department of Radiology, The University of North Carolina at Chapel Hill, Chapel Hill, USA.
| | - Jeffrey Forris Beecham Chick
- Section of Vascular and Interventional Radiology, Department of Radiology, University of Washington, Seattle, USA
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