Duplex Guided Dialysis Access Interventions can be Performed Safely in the Office Setting: Techniques and Early Results

Duplex ultrasound-guided angioplasty of hemodialysis vascular access

OBJECTIVE

Duplex ultrasound-guided angioplasty (DA) for hemodialysis vascular accesses remains questionable regarding its feasibility and safety. Minor complications (requiring no more treatment than nominal therapy) might be over-reported. Our hypothesis is that this procedure has no significant differences between observed rates and the recommended threshold of main outcomes of the procedure defined by the standards of arteriovenous fistulas (AVF) angioplasty.

METHODS

In a single-center retrospective study, 298 DA performed on 141 patients from 2015 to 2019 were analyzed. Occluded AVF or concomitant use of radiographic guidance were excluded. Duplex ultrasound parameters were collected up to 1 month before, at the end of angioplasty, and on day 30 after the procedure. Complications were registered, and patency rates were studied at 24 months of follow-up.

RESULTS

Anatomical success was achieved in 142 procedures (47.7%), clinical success in 284 (95.3%), and hemodynamic success in 283 (95.0%). Major complications-requiring at least a specific therapy-were reported in 8 procedures (2.7%) and minor complications-requiring no adjunctive therapy-in 157 (52.7%). At 24 months, overall postintervention primary patency was 34.0%, primary-assisted patency 87.4%, and secondary patency 92.5%. There were no significant differences of patency rates between groups with or without minor complications (P value for primary patency, 0.08; primary-assisted patency, 0.08; secondary patency, 0.23) or 30% residual stenosis (P value for primary patency, 0.82; primary-assisted patency, 0.46; secondary patency: 0.63). Duplex parameters further improved at postoperative day 30 after angioplasty.

CONCLUSIONS

DA of AVF is feasible, safe-despite over-reported minor complications having no impact on postintervention patency rates-and efficient. A minor complication can be seen as an event without bad or good consequences. Anatomical definition of success does not fit on DA for hemodialysis vascular access. Further studies are required to define the duplex parameter threshold for efficacy.

ACR Appropriateness Criteria® Dialysis Fistula Malfunction

The creation and maintenance of a dialysis access is vital for the reduction of morbidity, mortality, and cost of treatment for end stage renal disease patients. One's longevity on dialysis is directly dependent upon the quality of dialysis. This quality hinges on the integrity and reliability of the access to the patient's vascular system. All methods of dialysis access will eventually result in dialysis dysfunction and failure. Arteriovenous access dysfunction includes 3 distinct classes of events, namely thrombotic flow-related complications or dysfunction, nonthrombotic flow-related complications or dysfunction, and infectious complications. The restoration of any form of arteriovenous access dysfunction may be supported by diagnostic imaging, clinical consultation, percutaneous interventional procedures, surgical management, or a combination of these methods. This document provides a rigorous evaluation of how variants of each form of dysfunction may be appraised and approached systematically. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

X-ray-guided and ultrasound-guided percutaneous transluminal angioplasty to treat arteriovenous fistula dysfunction in hemodialysis patients: A retrospective controlled study

PURPOSE

To compare the safety and efficacy of X-ray-guided and ultrasound-guided percutaneous transluminal angioplasty in treating arteriovenous fistula dysfunction.

MATERIALS AND METHODS

Data for 219 patients with arteriovenous fistula dysfunction between January 2016 and December 2018 were retrospectively analyzed. The primary endpoints were technical success, clinical success, and primary patency rates. The secondary endpoints were complications and secondary patency rates. Procedure outcomes and both endpoints were evaluated by propensity score analysis.

RESULTS

After the propensity score matching, 73 matched pairs of cases were created with 34 pairs of autogenous arteriovenous fistula cases and 39 pairs of prosthetic arteriovenous graft cases. There was no significant difference between the X-ray-guided and ultrasound-guided group, respectively, regarding the technical success rate (84.9% vs 87.7%, p = 0.630), clinical success rate (98.6% vs 97.3%, p = 0.999), and complications (10.9% vs 5.5%, p = 0.228). Although the 6- and 12-month secondary patency rates for the dialysis access between the two groups had significant difference (p < 0.05), there was no significant difference in primary and secondary patency curves between the two groups (p > 0.05).

CONCLUSION

The overall efficacy of ultrasound-guided versus X-ray-guided percutaneous transluminal angioplasty in treating arteriovenous fistula dysfunction might be comparable.

Feasibility of routine ultrasound-guided percutaneous transluminal angioplasty in the treatment of native arteriovenous fistula dysfunction

BACKGROUND

Stenosis is the main cause of arteriovenous fistula failure and is due to neointimal hyperplasia. Percutaneous transluminal angioplasty is the gold standard for patients with vascular access stenosis. The aim of the study was to evaluate the efficacy and safety of ultrasound-guided percutaneous transluminal angioplasty in the treatment of native arteriovenous fistula venous stenosis.

METHODS

The need for intervention was determined by physical examination and duplex ultrasound in 162 patients. All patients with failing or not maturing arteriovenous fistula were treated in the outpatient setting under ultrasound guidance. Procedural success was assessed with repeated post-procedural ultrasound examinations. All procedures were performed under local anesthesia by a single nephrologist and were performed in a single vascular laboratory, while follow-up ultrasound was performed in the dialysis unit of destination.

RESULTS

Early technical success was obtained in 95.6% of cases (154 of 162). Complications occurred in 22 patients (13.5%) with no major complication requiring surgical or fluoroscopic endovascular intervention. Primary patency at 6 and 12 months was 84% and 69.8%, respectively. Risk factors for arteriovenous fistula failure/secondary percutaneous transluminal angioplasty were vascular access low blood flow rate and vintage, as well as the need for thrombolysis during the first percutaneous transluminal angioplasty.

CONCLUSION

Ultrasound-guided percutaneous transluminal angioplasty is a valuable tool to treat vascular access stenosis.

Ultrasound-guided Angioplasty of Arteriovenous Fistulas for Hemodialysis: Benefits and Limitations

BACKGROUND

Ultrasound-guided percutaneous angioplasty of arteriovenous fistulas (AVFs) makes it possible to avoid contrast agents and X-rays, to optimize the puncture site and to locate some stenoses on the fistulography, but is it really useful? Our objective is to report the results of our experience.

METHODS

Between November 2012 and November 2017, all the patients treated according to this method in our center were collected retrospectively. The surgical indications were an insufficient maturation of the AVF, an increase in the venous pressure, an inadequate outflow, difficulties in puncture, a prolonged bleeding time, a flow drop, or an aneurysmal evolution.

RESULTS

During this period, 50 patients had 72 ultrasound-guided angioplasties, 64 on native AVFs (88.9%) and 8 on prosthetic AVFs (11.1%). The technical success rate was 100%. The average preoperative flow of AVFs was 506.8 ± 302.2 vs. 955.9 ± 371.4 mL/min after angioplasty. The mean duration of follow-up was 13.4 ± 12.9 months. The cumulative rates of primary, assisted primary, and secondary patency were 43.5%, 68.8%, 81.5% at 1 year and 31.7%, 63.9%, 76.8% at 2 years, respectively.

CONCLUSIONS

AVF angioplasty under ultrasound guidance only is feasible, effective, and represents an interesting alternative. A controlled study comparing ultrasound guidance with angioplasties performed under conventional angiographic guidance as the reference technique would better clarify the value of this technique.

Predicting Technical Success after Fistuloplasty: An Analysis of 176 Procedures

BACKGROUND

Significant stenoses in arteriovenous fistulae (AVFs) or arteriovenous grafts (AVGs) with limitation of flow and dialysis inadequacy should prompt consideration for fistuloplasty. We sought to identify fistulae, lesions, and patient-specific variables, which predict for outcomes after fistuloplasty.

METHODS

Data were extracted retrospectively from a renal access database from 2011 to 2016 of patients undergoing fistuloplasty. Demographics, comorbidities, outcomes of intervention, and flow rates documented on preintervention and postintervention duplex were collected. Secondary analysis of factors associated with postfistuloplasty flow rates of >600 mL/min, previously shown to be predictive of not requiring future intervention, was performed.

RESULTS

Of 204 attempted fistuloplasties, 176 were completed. One hundred forty (79.5%) were native AVFs and 34 (19.3%), AVGs (no data for 2). Median stenosis treated was 75%, with a majority (43.8%) in the proximal outflow vein. Flow rate on duplex after fistuloplasty was significantly better in AVFs (mean improvement 189.2 mL/min) than that in AVGs (mean improvement 51.8 mL/min; P = 0.034). Greatest flow improvement occurred for needling site stenotic lesions compared with other locations (from anastomosis to central vein) but was not significant. Brachio-brachial or brachio-axillary AVGs did significantly (P < 0.05) worse than all other fistulae types. The presence of hypertension was predicted for postfistuloplasty flow rate of >600 mL/min.

CONCLUSIONS

Flow rates after fistuloplasty vary depending on the type of fistula treated and the presence of hypertension. Knowledge of this can lead to better patient selection and counseling for fistuloplasty.