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Shahverdyan R, Lessne ML, Mehta TI. Comparison of Outcomes of Drug-Coated Balloons versus Plain Balloons in Secondary Interventions on Percutaneous Arteriovenous Fistulae. J Vasc Interv Radiol 2024; 35:1176-1186.e1. [PMID: 38685469 DOI: 10.1016/j.jvir.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 03/24/2024] [Accepted: 04/21/2024] [Indexed: 05/02/2024] Open
Abstract
PURPOSE To compare patency and reintervention outcomes after either plain old balloon angioplasty (POBA) or drug-coated balloon angioplasty (DCBA) for venous stenoses after percutaneous arteriovenous fistula (pAVF) creation. MATERIALS AND METHODS One-hundred ninety-five pAVFs were successfully created during the study period, 141 using Ellipsys and 54 using Wavelinq. After pAVF creation, 95 patients (48.7%) required secondary percutaneous transluminal angioplasty (PTA) with either POBA (n = 55, 58%) or DCBA (n = 40, 42.1%). The most common site for PTA was the juxta-anastomotic segment (75.5%; 74/98). Univariate and multivariate Cox regression analyses were used to compare target lesion primary patency, access circuit primary patency, secondary patency, and reintervention rates in the POBA and DCBA cohorts. RESULTS Thirty-four of 55 (62%) patients in the POBA cohort and 14 of 40 (35%) patients in the DCBA cohort required reinterventions for pAVF restenosis. Mean number of follow-up days among patients treated with POBA was 1,030.4 (SD ± 342.9) and among those treated with DCBA was 744.4 (SD ± 403.5). The use of POBA compared with DCBA was not associated with target lesion and access circuit primary patency loss in multivariate analysis (hazard ratio [HR], 1.81; 95% CI, 0.93-3.51; P = .080; and HR, 1.77; 95% CI, 0.73-4.28; P = .210, respectively). However, time from fistula creation to the first PTA (days) was statistically significantly associated with both outcomes (HR, 0.997; 95% CI, 0.994-0.999; P = .009; and HR, 0.997; 95% CI, 0.992-0.999; P = .021, respectively). There were no major adverse events. CONCLUSIONS In this retrospective single-center analysis of pAVFs, considerably more patients who underwent PTA with POBA after pAVF creation required reinterventions compared with PTA using DCBA, although the follow-up time of POBA was longer. In multivariate analysis, no differences were noted in the hazard of patency loss between POBA and DCBA.
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Affiliation(s)
| | - Mark L Lessne
- Vascular & Interventional Specialists, Charlotte Radiology, Charlotte, North Carolina; Department of Radiology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Tej Ishaan Mehta
- Department of Radiology, The Johns Hopkins Hospital, Baltimore, Maryland
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Lee H, Choi H, Han E, Kim YJ. Comparison of Clinical Effectiveness and Safety of Drug-Coated Balloons versus Percutaneous Transluminal Angioplasty in Arteriovenous Fistulae: A Review of Systematic Reviews and Updated Meta-Analysis. J Vasc Interv Radiol 2024; 35:949-962.e13. [PMID: 38554948 DOI: 10.1016/j.jvir.2024.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/14/2024] [Accepted: 03/23/2024] [Indexed: 04/02/2024] Open
Abstract
PURPOSE To evaluate the clinical effectiveness and safety of drug-coated balloons (DCBs) compared with those of percutaneous transluminal angioplasty (PTA) for arteriovenous fistula (AVF) stenosis via a review of systematic reviews (SRs) and an update of the current meta-analysis. MATERIALS AND METHODS Literature was searched to retrieve SRs comparing DCBs and PTA for AVFs. A narrative review of SRs and pooled analysis were performed. RESULTS Eleven SRs were included. DCBs demonstrated favorable outcomes at 6 and 12 months compared with PTA, with improved patency in 7 SRs and a trend toward favorable outcomes without statistical significance in 3 SRs. Target lesion revascularization (TLR) was reported in 3 SRs; 2 reviews reported a significantly lower incidence in the DCB group than in the PTA group, whereas 1 review reported no significant differences at 12 months. Four studies reporting all-cause mortality revealed no significant difference between the 2 treatments. In the updated meta-analysis including 23 studies, DCBs demonstrated improved primary patency at 6 months (risk ratio [RR], 1.27; 95% CI, 1.07-1.50) and 12 months (RR, 1.36; 95% CI, 1.19-1.55) and were associated with a lower incidence of TLR at 6 months (RR, 0.54; 95% CI, 0.41-0.73) and 12 months (RR, 0.78; 95% CI, 0.62-0.99). There was no difference in mortality between the 2 groups for 24 months. CONCLUSIONS A review of SRs and meta-analysis update revealed the consistent benefits of DCBs over PTA in treating AVFs in terms of primary patency and TLR. Compared with PTA, DCBs do not increase mortality risk.
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MESH Headings
- Humans
- Coated Materials, Biocompatible
- Angioplasty, Balloon/adverse effects
- Angioplasty, Balloon/instrumentation
- Angioplasty, Balloon/mortality
- Treatment Outcome
- Arteriovenous Shunt, Surgical/adverse effects
- Arteriovenous Shunt, Surgical/mortality
- Vascular Patency
- Graft Occlusion, Vascular/therapy
- Graft Occlusion, Vascular/etiology
- Graft Occlusion, Vascular/physiopathology
- Graft Occlusion, Vascular/diagnostic imaging
- Risk Factors
- Renal Dialysis
- Vascular Access Devices
- Equipment Design
- Time Factors
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Affiliation(s)
- Haine Lee
- Department of Pharmaceutical Medicine and Regulatory Sciences, College of Medicine and Pharmacy, Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon, Republic of Korea
| | - Hyunsook Choi
- Government Affairs and Market Access, Medtronic Korea, Seoul, Republic of Korea
| | - Euna Han
- Department of Pharmaceutical Medicine and Regulatory Sciences, College of Medicine and Pharmacy, Yonsei Institute of Pharmaceutical Sciences, Yonsei University, Incheon, Republic of Korea
| | - Yong Jae Kim
- Department of Radiology, Soon Chun Hyang University, Seoul, Republic of Korea.
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Zhao Y, Wang P, Wang Y, Zhang L, Zhao Y, Li H, He Q, Liu H, Luo J, Jia X, Yu Z, Guo W, Zhang L. Drug-Coated Balloon Angioplasty for Dysfunctional Arteriovenous Hemodialysis Fistulae: A Randomized Controlled Trial. Clin J Am Soc Nephrol 2024; 19:336-344. [PMID: 38191561 PMCID: PMC10937027 DOI: 10.2215/cjn.0000000000000359] [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] [Received: 05/31/2023] [Accepted: 12/06/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND The aim of this study was to evaluate the efficacy and safety of paclitaxel-coated balloons (AcoArt Orchid) in treating dysfunctional arteriovenous fistulae. METHODS The drug-eluting balloon for arteriovenous (AV) fistula in China trial was a prospective, multicenter, randomized controlled study. Patients who had ≥50% venous stenosis of the AV fistula and symptoms indicating significant hemodynamic changes were included. After successful predilation with a high-pressure balloon (residual stenosis ≤30%), patients were randomized 1:1 to either a paclitaxel-coated balloon or an uncoated control balloon. The primary efficacy outcome was assessed at 6 months, and safety assessment was conducted within 30 days of the procedure. The 12-month results were also analyzed. RESULTS The study included 244 patients, equally distributed between the two groups. The primary target lesion patency was 91% (106/116) for the drug-coated balloon (DCB) group and 67% (79/118) for the plain balloon catheter group, representing a difference of 24.63% (95% confidence interval, 14.68 to 34.58; P < 0.001). The secondary efficacy end point was primary target lesion patency at 12 months, which was 66% (74/112) for the DCB group and 46% (52/112) for the plain balloon catheter group (95% confidence interval, 6.57 to 32.08; P = 0.004). The mean number of reinterventions per patient to maintain target lesion patency during the 12 months after the index procedure was 0.39 (48/122) in the DCB group and 0.77 (94/122) in the plain balloon catheter group ( P = 0.001). The primary safety end point did not differ between groups ( P = 0.25). CONCLUSIONS AcoArt Orchid DCB showed better primary patency rates compared with plain balloon angioplasty for treating stenotic lesions in dysfunctional hemodialysis AV fistulae at 6 and 12 months. It required fewer repeated interventions and had comparable safety in 1 year. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER AcoArt III/Arterio-venous Fistula in China, NCT03366727 .
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Affiliation(s)
- Yiping Zhao
- Vascular Surgery Department, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Pei Wang
- Blood Purification Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou University, Zhengzhou, China
| | - Yuzhu Wang
- Nephrology Department, Beijing Haidian Hospital, Beijing, China
| | - Lihong Zhang
- Nephrology Department, The First Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, China
| | - Yu Zhao
- Vascular Surgery Department, The First Affiliated Hospital of Chongqing Medical University, Chongqing Medical University, Chongqing, China
| | - Hua Li
- Nephrology Department, Shaoyifu Hospital, Zhejiang Medical University, Hangzhou, China
| | - Qiang He
- Nephrology Department, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Hao Liu
- Vascular and Interventional Radiology Department, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianfang Luo
- Cardiology Department, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Xin Jia
- Vascular Surgery Department, Chinese PLA General Hospital, Beijing, China
| | - Zhengya Yu
- Vascular Surgery Department, Tongren Hospital, Capital Medical University, Beijing, China
| | - Wei Guo
- Vascular Surgery Department, Chinese PLA General Hospital, Beijing, China
| | - Lan Zhang
- Vascular Surgery Department, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai Jiaotong University, Shanghai, China
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Reppas L, Spiliopoulos S, Kitrou P, Katsanos K, Papadimatos P, Vaiou M, Lampropoulos G, Moulas AN, Karnabatidis D, Brountzos E. Evaluation of a new paclitaxel-coated balloon catheter in an in vivo porcine peripheral venous model: Feasibility, safety, and drug deliverability. J Vasc Access 2024; 25:504-511. [PMID: 36113056 DOI: 10.1177/11297298221122115] [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: 02/18/2024] Open
Abstract
PURPOSE To evaluate in vivo the feasibility, safety, and paclitaxel (PTX) deliverability of a newly developed non-commercially available Paclitaxel-Coated Balloon (PCB) catheter in the swine healthy peripheral vein model. MATERIALS AND METHODS In total 12 PCBs were deployed in 12 venous segments. Primary feasibility endpoint was the successful application of the devices to the veins of the animals. Primary efficacy endpoint was the determination of the drug content in the venous tissue at 24 h and 7 days after balloon expansion, as assessed by analysis of the vein tissue with High Performance Liquid Chromatography (HPLC) coupled with tandem mass spectrometry. Primary safety endpoint was freedom from any major adverse event. Secondary endpoint was the investigation of any independent factor affecting the primary endpoints. RESULTS Paclitaxel was detected in five out of six tissue samples 24 h post-intervention and five out of six tissues at 7 days following the procedure (10 tissue samples out of 12). The mean weight of tissue that was examined was 0.20604 ± 0.29822 g (range: 1.02823-0.03377 g) and the mean PTX concentration detected was 8.4 ± 13.1 μg/g (range: 0-36.1 μg/g). The average drug content detected at 24 h (17.1 ± 17.1 μg/g) was numerically superior, but non-statistically significant, compared to 7 days (3.1 ± 3.6 μg/g). An average of 33.8% of the drug remained on the balloon after retrieval. According to the multiple linear regression analysis, there was no significant correlation between transition time, PTX remaining on the balloon, time of analysis (24 h/7 days) and PTX tissue concentration. No abnormalities were noted during autopsy. CONCLUSION The newly developed PCB successfully delivered within the healthy venous wall a dose of Paclitaxel that inhibits neointimal hyperplasia. No safety issues were raised at short-term follow-up.
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Affiliation(s)
- Lazaros Reppas
- Second Department of Radiology, Interventional Radiology Unit, School of Medicine, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, School of Medicine, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Panagiotis Kitrou
- Department of Interventional Radiology, School of Medicine, Patras University Hospital, Rion, Greece
| | - Konstantinos Katsanos
- Department of Interventional Radiology, School of Medicine, Patras University Hospital, Rion, Greece
| | - Panagiotis Papadimatos
- Department of Interventional Radiology, School of Medicine, Patras University Hospital, Rion, Greece
| | - Maria Vaiou
- General Department, University of Thessaly, Larissa, Greece
| | | | | | - Dimitrios Karnabatidis
- Department of Interventional Radiology, School of Medicine, Patras University Hospital, Rion, Greece
| | - Elias Brountzos
- Second Department of Radiology, Interventional Radiology Unit, School of Medicine, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
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Goo DE, Kim YJ, Park SW, Cheon HJ, Won YD, Yang SB. A Prospective Multicenter Randomized Controlled Trial for Comparing Drug-Coated and Conventional Balloon Angioplasty in Venous Anastomotic Stenosis of Hemodialysis Arteriovenous Grafts. Cardiovasc Intervent Radiol 2024; 47:36-44. [PMID: 38010504 DOI: 10.1007/s00270-023-03536-5] [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: 05/07/2023] [Accepted: 08/07/2023] [Indexed: 11/29/2023]
Abstract
PURPOSE To evaluate the efficacy and safety of drug-coated balloon angioplasty compared to conventional balloon angioplasty in the treatment of dysfunctional arteriovenous grafts. MATERIALS AND METHODS This prospective, multicenter, randomized clinical trial enrolled 190 patients with venous anastomotic stenosis in arteriovenous grafts at five participating hospitals. During pre-dilation, 4 patients dropped out due to ruptures requiring further treatment (n = 2) and residual stenosis of > 30% (n = 2). On successful pre-dilation with a 7 mm conventional balloon, patients were randomized to undergo either a 7 mm drug-coated balloon (n = 94) or conventional balloon angioplasty (n = 92). The primary out-come measure was target lesion primary patency at 3 and 6 months. The secondary out-come measures included target lesion primary patency at 12 months and access circuit primary patency at 6 and 12 months, clinical and technical success rates, and 12-month mortality differences between the groups. RESULTS The target lesion primary patency and access circuit patency rates at 3 and 6 months were significantly higher in drug-coated balloon angioplasty group as compared to conventional balloon angioplasty group. The technical and clinical success rates were 100% for both the groups. As a procedure-related complication, anastomotic site rupture occurred during pre-dilation in 4 cases. The number of deaths during the 12-month follow-up was one for each group. The number of early thrombotic events (at < 3 months) was significantly higher in the drug-coated balloon group (p = 0.002). CONCLUSION Drug-coated balloon angioplasty was more effective and safer for the treatment of dysfunctional arteriovenous grafts compared to conventional balloon angioplasty.
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Affiliation(s)
- Dong Erk Goo
- Department of Radiology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, 59 Daesagwan-gil, Hannam-dong, Yongsan-gu, Seoul, 04401, South Korea.
| | - Yong Jae Kim
- Department of Radiology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, 59 Daesagwan-gil, Hannam-dong, Yongsan-gu, Seoul, 04401, South Korea
| | - Sang Woo Park
- Department of Radiology, Konkuk University Hospital, Konkuk University College of Medicine, Seoul, Korea
| | - Ho Jong Cheon
- Department of Radiology, Seoul St Mary's Hospital, Catholic University College of Medicine, Seoul, Korea
| | - You Dong Won
- Department of Radiology, Uijeongbu St Mary's Hospital, Catholic University College of Medicine, Uijeongbu, Korea
| | - Seung Boo Yang
- Department of Radiology - Intervention Division, Nowon Eulji University Hospital, 68 Hangeul biseok-ro, Nowon-gu, Seoul, 01830, Korea
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Maleux G, van der Linden E, Heijboer RJJ, Serafino GP, Wüst AFJ, Dol JA, Gabriels K, Pattynama P. Multicenter Randomized Controlled Trial of APERTO-Paclitaxel Drug-Eluting Balloon Angioplasty Versus Standard Percutaneous Transluminal Angioplasty in Dysfunctional Hemodialysis Grafts and Native Fistulae. J Endovasc Ther 2023:15266028231215212. [PMID: 38053508 DOI: 10.1177/15266028231215212] [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: 12/07/2023]
Abstract
PURPOSE to assess the safety and efficacy of APERTO-Paclitaxel-coated balloon angioplasty versus standard angioplasty for the treatment of dysfunctional hemodialysis shunts and native arteriovenous fistulae. METHODS consecutive patients with dysfunctional dialysis related to underlying efferent vein stenosis were included and randomized 1:1 to either APERTO-paclitaxel drug-coated balloon (study arm) or standard percutaneous transluminal angioplasty (control arm). Primary endpoint is time from treatment until dialysis access dysfunction according to standardized Kidney Disease Outcomes Quality Initiative (KDOQI)-guidelines and assessed by Kaplan-Meier survival curves and tested for significance with log-rank analysis. Secondary endpoints include device, technical, and clinical success of the index angioplasty procedure. RESULTS The study included 103 patients (n=51 study-group) with a de novo (n=33) dysfunctional native arteriovenous fistula (n=79) in the forearm (n=60). The majority of included patients were male with a mean age of 69.8 years, presenting with a dysfunctioning autologous arteriovenous fistula in the forearm. Device-related complications did not occur in any of the included patients. Functional hemodialysis access without need for re-intervention at 1 year after index procedure was found in n=10 (19.6%) and n=5 (9.6%) of patients treated with, respectively, paclitaxel drug-coated balloon and percutaneous transluminal angioplasty (p=0.612). A nonsignificant benefit of paclitaxel drug-coated balloon (n=5; 25%) over percutaneous transluminal angioplasty (n=1; 11%) was found (p=0.953) in de novo lesions in autologous fistulas. CONCLUSION APERTO-paclitaxel drug-coated balloon is a safe balloon catheter to manage dysfunctional hemodialysis access; however, longer period of adequate hemodialysis circuit functioning after endovascular index stenosis treatment, using APERTO-paclitaxel drug-coated balloon versus percutaneous transluminal angioplasty could not be demonstrated. CLINICAL IMPACT APERTO-paclitaxel drug-coated balloon catheter is a safe device to manage dysfunctional hemodialysis access. Compared to conventional angioplasty balloon, the APERTO drug-coated balloon will not result in longer period of adequate hemodialysis circuit functioning. A non-significant benefit of APERTO drug-coated balloon was found in de novo lesions in autologous fistulas.
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Affiliation(s)
| | | | | | | | - Aloys F J Wüst
- Onze Lieve Vrouwe Gasthuis West, Amsterdam, The Netherlands
| | - Johan A Dol
- Medical Center Leeuwarden, Leeuwarden, The Netherlands
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Echefu G, Stowe I, Lukan A, Sharma G, Basu-Ray I, Guidry L, Schellack J, Kumbala D. Central vein stenosis in hemodialysis vascular access: clinical manifestations and contemporary management strategies. FRONTIERS IN NEPHROLOGY 2023; 3:1280666. [PMID: 38022724 PMCID: PMC10664753 DOI: 10.3389/fneph.2023.1280666] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023]
Abstract
Central venous stenosis is a significant and frequently encountered problem in managing hemodialysis (HD) patients. Venous hypertension, often accompanied by severe symptoms, undermines the integrity of the hemodialysis access circuit. In central venous stenosis, dialysis through an arteriovenous fistula is usually inefficient, with high recirculation rates and prolonged bleeding after dialysis. Central vein stenosis is a known complication of indwelling intravascular and cardiac devices, such as peripherally inserted central catheters, long-term cuffed hemodialysis catheters, and pacemaker wires. Hence, preventing this challenging condition requires minimization of central venous catheter use. Endovascular interventions are the primary approach for treating central vein stenosis. Percutaneous angioplasty and stent placement may reestablish vascular function in cases of elastic and recurrent lesions. Currently, there is no consensus on the optimal treatment, as existing management approaches have a wide range of patency rates.
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Affiliation(s)
- Gift Echefu
- Division of Cardiovascular Medicine, The University of Tennessee Health Science Center, Memphis, TN, United States
| | - Ifeoluwa Stowe
- Department of Internal Medicine, Baton Rouge General Medical Center, Baton Rouge, LA, United States
| | - Abdulkareem Lukan
- Department of Internal Medicine, Advocate Illinois Masonic Medical Center, Chicago, IL, United States
| | - Gaurav Sharma
- Department of Nephrology, AIIMS Rishikesh, Rishikesh, India
| | - Indranill Basu-Ray
- Department of Cardiology, AIIMS Rishikesh, Rishikesh, India
- Department of Cardiovascular Disease, Memphis Veterans Affairs Medical Center, Memphis, TN, United States
| | - London Guidry
- Vascular Clinic of Baton Rouge, Baton Rouge, LA, United States
| | - Jon Schellack
- Vascular Clinic of Baton Rouge, Baton Rouge, LA, United States
| | - Damodar Kumbala
- Vascular Clinic of Baton Rouge, Baton Rouge, LA, United States
- Renal Associates of Baton Rouge, Baton Rouge, LA, United States
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Ratnam L, Karunanithy N, Mailli L, Diamantopoulos A, Morgan RA. Dialysis Access Maintenance: Plain Balloon Angioplasty. Cardiovasc Intervent Radiol 2023; 46:1136-1143. [PMID: 37156943 PMCID: PMC10471649 DOI: 10.1007/s00270-023-03441-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/31/2023] [Indexed: 05/10/2023]
Abstract
Plain balloon angioplasty remains the first-line treatment for dialysis access stenosis. This chapter reviews the outcomes of plain balloon angioplasty from cohort studies and comparative studies. Angioplasty outcomes are more favourable in arteriovenous fistulae (AVF) compared to arteriovenous grafts (AVG) with primary patency at 6 months ranging from 42-63% compared to 27-61%, respectively, and improved for forearm fistulae compared with upper arm fistulae. Higher pressures are required to treat stenoses in AVFs compared to AVGs. Outcomes are worse in more severe stenoses, increased patient age, previous interventions and fistulae that develop early stenoses. Major complication rates following angioplasty in dialysis access are between 3 and 5%. Repeat treatments and the use of adjuncts such as drug-coated balloons and stents can prolong the patency of dialysis access. Level of Evidence No level of evidence (Review paper).
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Affiliation(s)
- Lakshmi Ratnam
- Department of Interventional Radiology, St George's University Hospitals NHS Foundation Trust, London, UK.
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK.
| | - Narayan Karunanithy
- Department of Interventional Radiology, Guys and St. Thomas NHS Foundation Trust, London, UK
- School of Biomedical Engineering & Imaging Sciences, Faculty of Life Sciences & Medicine, Kings College London, London, UK
| | - Leto Mailli
- Department of Interventional Radiology, St George's University Hospitals NHS Foundation Trust, London, UK
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK
| | - Athanasios Diamantopoulos
- Department of Interventional Radiology, Guys and St. Thomas NHS Foundation Trust, London, UK
- School of Biomedical Engineering & Imaging Sciences, Faculty of Life Sciences & Medicine, Kings College London, London, UK
| | - Robert A Morgan
- Department of Interventional Radiology, St George's University Hospitals NHS Foundation Trust, London, UK
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK
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9
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Kitrou P, Katsanos K, Karnabatidis D. Management of Central Venous Stenoses and Occlusions. Cardiovasc Intervent Radiol 2023; 46:1182-1191. [PMID: 37460644 PMCID: PMC10471665 DOI: 10.1007/s00270-023-03461-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 05/01/2023] [Indexed: 09/02/2023]
Abstract
Symptomatic central venous stenosis and occlusion remains the gordian knot of vascular access. Advances in techniques, like sharp recanalization, allowed for improved success rates in crossing these difficult lesions. There is also increasing evidence of new devices in treating central venous stenosis and, at the same time, improving the time needed between interventions. High-pressure balloons, paclitaxel-coated balloons, bare metal stents and covered stents have been tested with an aim to offer additional treatment options, although obstacles still exist. In the current review, authors describe relevant techniques and options, provide the evidence and evaluate the actual implementation of these devices in this demanding field.
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Affiliation(s)
- Panagiotis Kitrou
- Interventional Radiology, Patras University Hospital, Patras, Greece.
- Medical School, University of Patras, Patras, Greece.
| | - Konstantinos Katsanos
- Interventional Radiology, Patras University Hospital, Patras, Greece
- Medical School, University of Patras, Patras, Greece
| | - Dimitrios Karnabatidis
- Interventional Radiology, Patras University Hospital, Patras, Greece
- Medical School, University of Patras, Patras, Greece
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10
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Li Y, Shi Z, Zhao Y, Cao Z, Tan Z. Long-term mortality and patency after drug-coated balloon angioplasty in the hemodialysis circuit: A systematic review and meta-analysis of randomized controlled trials. J Vasc Access 2023; 24:1104-1113. [PMID: 35001726 DOI: 10.1177/11297298211070125] [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: 11/16/2022] Open
Abstract
PURPOSE To compare all-cause mortality and primary patency with drug-coated balloon angioplasty (DCBA) compared with plain balloon angioplasty (PBA) in people with hemodialysis-related stenosis. MATERIALS AND METHODS PubMed, Embase, and Cochrane Library databases were searched from November 1966 to February 2021 to identify randomized controlled trials (RCTs) that assessed the use of DCBA versus PBA for stenosis in hemodialysis circuits. Data extracted from the articles were integrated to determine all-cause mortality, target lesion primary patency (TLPP), circuit access primary patency (CAPP), 30-day adverse events, and technical success for the two approaches. We performed meta-analysis on these results using a fixed-effects model to evaluate odds ratios (ORs) and 95% confidence intervals (CIs) where I2 < 50% in a test for heterogeneity, or a random-effect model if otherwise. Sensitivity and subgroup analyses were also performed. RESULTS Sixteen RCTs of 1672 individuals were included in our meta-analysis, of which 839 individuals received DCBA and 833 received PBA. The pooled outcome showed no statistical difference between DCBA and PBA in all-cause mortality at 6 months (OR = 1.29, 95% CI = 0.72-2.32, p = 0.39, I2 = 4%), 12 months (OR = 1.02, 95% CI = 0.68-1.53, p = 0.91, I2 = 0%), and 24 months (OR = 1.50, 95% CI = 0.87-2.57, p = 0.15, I2 = 0%), 30-day adverse events (OR = 1.09, 95% CI = 0.30-3.98, p = 0.90, I2 = 66%), and technical success (OR = 0.18, 95% CI = 0.02-1.92, p = 0.16, I2 = 65%). The DCBA had significantly better outcomes versus PBA in TLPP at 6 months (OR = 2.37, 95% CI = 1.84-3.04, p < 0.001, I2 = 44%) and 12 months (OR = 1.77, 95% CI = 1.22-2.56, p = 0.002, I2 = 56%), and CAPP at 6 months (OR = 2.07, 95% CI = 1.21-3.54, p = 0.008, I2 = 67%) and 12 months (OR = 1.66, 95% CI = 1.29-2.15, p < 0.001, I2 = 0%). CONCLUSION In hemodialysis circuit stenosis, DCBA appears to have similar safety but greater efficacy than PBA.
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Affiliation(s)
- Yunfeng Li
- Deparment of Nephrology, The First hospital of Tsinghua University, Beijing, China
| | - Zhenwei Shi
- Deparment of Nephrology, The First hospital of Tsinghua University, Beijing, China
| | - Yunyun Zhao
- Department of Nuclear Medicine, Peking University People's Hospital, Beijing, China
| | - Zhanjiang Cao
- Department of Vascular Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Zhengli Tan
- Department of Vascular Surgery, Tongren Hospital of Capital Medical University, Beijing, China
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11
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Zhang Y, Yuan F, Hu X, Wang Q, Zou Z, Li Z. Comparison of drug-coated balloon angioplasty versus common balloon angioplasty for arteriovenous fistula stenosis: A systematic review and meta-analysis. Clin Cardiol 2023; 46:877-885. [PMID: 37417371 PMCID: PMC10436783 DOI: 10.1002/clc.24078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 06/12/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023] Open
Abstract
Drug-coated balloons (DCBs) have been used in dialysis patients with arteriovenous fistula (AVF) stenosis, but whether DCBs have advantages over ordinary balloons is still controversial. A meta-analysis was designed to investigate the safety and efficacy of DCBs and common balloons (CBs) in the treatment of AVF stenosis. We searched the PubMed, EMBASE, and China National Knowledge Internet (CNKI) databases for randomized controlled trials that evaluated the comparison of DCB angioplasty versus CB angioplasty for AVF stenosis in dialysis patients and reported at least one outcome of interest. The results showed that the DCB group had a higher first-stage patency rate of the target lesion 6 months [odds ratio, OR = 2.31, 95% confidence interval, CI: (1.69, 3.15), p < .01] and 12 months [OR = 2.09, 95% CI: (1.50, 2.91), p < .01] after surgery. There was no statistically significant difference in all-cause mortality between the two groups at 6 months [OR = 0.85, 95% CI: (0.47, 1.52), p = .58] and 12 months [OR = 0.99, 95% CI: (0.60, 1.64), p = .97]. Compared with CB, DCBs as a new endovascular treatment for AVF stenosis have a higher primary patency rate of target lesions and can delay the occurrence of restenosis. There is no evidence that DCB can increase the mortality of patients.
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Affiliation(s)
- Yong Zhang
- Department of NephrologyJianli People's HospitalJingzhouChina
| | - Fan‐Li Yuan
- Department of NephrologyThe First Affiliated Hospital of Yangtze UniversityJingzhouChina
| | - Xiang‐Yang Hu
- Department of EmergencyThe Central Hospital of Enshi Tujia and Miao Autonomous PrefectureEnshiChina
| | - Qi‐Bing Wang
- Department of EmergencyThe Central Hospital of Enshi Tujia and Miao Autonomous PrefectureEnshiChina
| | - Zhen‐Wu Zou
- Department of General PracticeThe Central Hospital of Enshi Tujia and Miao Autonomous PrefectureEnshiChina
| | - Zhen‐Guo Li
- Department of PediatricsJianli People's HospitalJingzhouChina
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12
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Tang TY, Soon SXY, Yap CJQ, Chan SL, Tan RY, Pang SC, Choke ETC, Tan CS, Chong TT. Use of the helical SUPERA™ stent and Passeo-18 Lux™ drug-coated balloon to treat recurrent cephalic arch stenosis for dysfunctional brachiocephalic fistulas: 1 year results of the Arch V SUPERA-LUX study. J Vasc Access 2023; 24:591-598. [PMID: 34473005 DOI: 10.1177/11297298211043083] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Aim of Arch V SUPERA-LUX was to evaluate the safety and efficacy of the combination therapy of SUPERA™ (Abbott Vascular, Santa Clara, CA, USA) helical stent implantation and Passeo-18 Lux™ (Biotronik Asia Pacific Pte Ltd, Singapore) drug coated balloon (DCB) elution to treat recurrent cephalic arch stenosis (CAS) in the setting of AV access dysfunction. METHODS Investigator-initiated, single-center, single-arm prospective pilot study of 20 end-stage renal failure Asian patients with a dysfunctional brachiocephalic fistula. All had symptomatic recurrent CAS within 6 months of prior intervention. The lesion was pre-dilated with a standard high-pressure balloon (Biotronik Passeo-35 HP balloon). The DCB (Passeo-18 Lux™) is subsequently inflated and the SUPERA™ stent deployed to sit 2 mm distal to the cephalic arch and covering the CAS but within the DCB zone. All patients were prescribed dual antiplatelet therapy for 3 months and followed up with Duplex ultrasound at 6- and 12-months. RESULTS There were 9 (45%) males and mean age was 67 ± 11.0 years. Mean time from prior procedure was 113 ± 68 days and main indication for reintervention was high venous pressure (9/20, 45%). Technical success was 100% and there were no peri-procedural complications related to either stent or DCB deployment. Target lesion primary patency at 6- and 12-months was 10/18 (55%) and 5/16 (31%), respectively. Mean time to target lesion re-intervention was 170 ± 82 days. Circuit access patency was 8/18 (44%) and 2/16 (13%) at 6- and 12-months respectively and mortality was 3/20 (15%) attributed to the patients' underlying co-morbidities. CONCLUSION Dual prong strategy of using SUPERA™ stenting and Passeo-18 Lux™ drug elution for recurrent CAS, although safe, was no more efficacious than conventional balloon angioplasty or stenting alone. Development of an intense inflammatory reaction within the stent led to reinterventions of a number of cases with suboptimal results.
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Affiliation(s)
- Tjun Yip Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
- Duke NUS Graduate Medical School, Singapore, Singapore
| | - Shereen Xue Yun Soon
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
| | - Charyl Jia Qi Yap
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
| | - Sze Ling Chan
- Health Services Research Center, SingHealth, Singapore, Singapore
| | - Ru Yu Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Suh Chien Pang
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | | | - Chieh Suai Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore
| | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
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13
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Tang TY, Chong TT, Yap CJQ, Soon SXY, Chan SL, Tan RY, Yap HY, Tay HT, Tan CS, Barnhill S, Hellinga D, DeGraw RT, Finn AV. Intervention with selution SLR™ Agent Balloon for Endovascular Latent Limus therapy for failing AV Fistulas (ISABELLA) Trial: Protocol for a pilot clinical study and pre-clinical results. J Vasc Access 2023; 24:289-299. [PMID: 34219511 PMCID: PMC10021111 DOI: 10.1177/11297298211020867] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The aim of this pilot clinical study is to evaluate the safety and efficacy of the Selution Sustained Limus Release (SLR)™ sirolimus-coated balloon (M.A. MedAlliance SA, Nyon, Switzerland) for improving the patency of failing arterio-venous fistulas (AVF) in hemodialysis patients. We also present herein a pre-clinical pharmacokinetic and safety evaluation of Selution™ to justify its first use in hemodialysis patients for endovascular access salvage. METHODS AND RESULTS This is an investigator-initiated prospective single-center, non-blinded single-arm trial. Forty patients with clinically significant de novo or recurrent stenoses in a mature AVF circuit will be recruited. All stenotic lesions will be prepared with high pressure non-compliant conventional balloon angioplasty (CBA) prior to deployment of the Sustained-Release Selution™ sirolimus drug-eluting balloon. The primary efficacy endpoint is 6-month target lesion primary patency and the primary safety endpoint is freedom from localized or systemic serious adverse events through 30 days. Secondary endpoints of interest include technical and clinical success rates and circuit access patency at 3 and 6 months. Follow-up will occur for 2 years for those patients whose AVFs remain patent. Pharmacokinetic and histological animal safety studies performed with the Selution™ coating formulation showed prolonged arterial tissue retention of sirolimus with therapeutic levels up to 60 days and non-toxic and rapidly declining blood levels. Histological results in animal models demonstrated safety, freedom from intraluminal thrombus, reduction in restenosis by sirolimus elution compared to CBA, and no evidence of embolic phenomena indicative of adverse particulate effects. DISCUSSION Long release sirolimus coated balloons may serve as a promising novel alternative therapy to paclitaxel-based technology for treating conduit stenosis secondary to neointimal hyperplasia. Pre-clinical pharmacokinetic and histological animal data are encouraging and provide suggestion of safety and efficacy in this setting. This single-center trial will provide a first step toward demonstration of efficacy and safety of this device for treatment of stenotic fistulas.
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Affiliation(s)
- Tjun Yip Tang
- Department of Vascular Surgery,
Singapore General Hospital, Singapore, Singapore
- Duke-NUS Graduate Medical School,
Singapore, Singapore
- Tjun Yip Tang, Duke-NUS Medical School,
Department of Vascular Surgery, Singapore General Hospital, Level 5; Academia,
20 College Road, Singapore 169856, Singapore.
| | - Tze-Tec Chong
- Department of Vascular Surgery,
Singapore General Hospital, Singapore, Singapore
| | - Charyl Jia Qi Yap
- Department of Vascular Surgery,
Singapore General Hospital, Singapore, Singapore
| | - Shereen Xue Yun Soon
- Department of Vascular Surgery,
Singapore General Hospital, Singapore, Singapore
| | - Sze Ling Chan
- Health Services Research Center,
SingHealth, Singapore, Singapore
| | - Ru Yu Tan
- Department of Renal Medicine, Singapore
General Hospital, Singapore, Singapore
| | - Hao Yun Yap
- Department of Vascular Surgery,
Singapore General Hospital, Singapore, Singapore
| | - Hsien Ts’ung Tay
- Department of Vascular Surgery,
Singapore General Hospital, Singapore, Singapore
| | - Chieh-Suai Tan
- Health Services Research Center,
SingHealth, Singapore, Singapore
| | | | | | | | - Aloke V Finn
- CVPath Institute Inc., Gaithersburg,
MD, USA
- University of Maryland School of
Medicine, Baltimore, MD, USA
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14
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Fransson T, Gottsäter A, Abdulrasak M, Malina M, Resch T. Drug-eluting balloon (DEB) versus plain old balloon angioplasty (POBA) in the treatment of failing dialysis access: A prospective randomized trial. J Int Med Res 2022; 50:3000605221081662. [PMID: 35354342 PMCID: PMC8978321 DOI: 10.1177/03000605221081662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To compare the efficacy of angioplasty using drug-eluting balloons (DEB) compared with plain old balloon angioplasty (POBA) to reduce the rate of restenosis. Methods This prospective, single-centre, single-blinded, 1:1 randomized, clinical trial enrolled patients that had primary or restenotic lesions in native upper extremity arteriovenous (AV) fistulas or at the graft-venous anastomosis. Patients were randomized to angioplasty with a POBA or a DEB. The primary effectiveness endpoints were freedom from target lesion revascularization (TLR) and functional status of access circuit at 12 months. Results A total of 42 (28 male, 14 female; age range, 42–83 years) patients were enrolled. Patients were followed for 12 months. No significant differences were detected between the POBA and DEB groups regarding total number of TLR procedures (31 versus 36, respectively), freedom from TLR (3 versus 4, respectively) and functional status of the access circuit at 12 months (14 of 20 patients [70%] versus 17 of 22 patients [77%], respectively). Conclusion This clinical trial did not demonstrate any significant differences between DEB angioplasty and standard balloon angioplasty when treating dysfunctional haemodialysis access.
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Affiliation(s)
- Torbjörn Fransson
- Department of Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden.,Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden
| | - Anders Gottsäter
- Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden.,Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden
| | - Mohammad Abdulrasak
- Department of Internal Medicine, Skåne University Hospital, Malmö, Sweden.,Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden
| | - Martin Malina
- West London Vascular and Interventional Centre, Northwick Park University Hospital, Harrow, UK
| | - Timothy Resch
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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15
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Kitrou P, Katsanos K, Georgopoulou GA, Karnabatidis D. Drug-Coated Balloons for the Dysfunctional Vascular Access: An Evidence-Based Road Map to Treatment and the Existing Obstacles. Semin Intervent Radiol 2022; 39:56-65. [PMID: 35210734 PMCID: PMC8856785 DOI: 10.1055/s-0042-1742483] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
An underlying stenosis within the venous limb of a hemodialysis access circuit is the main etiology for graft and fistula dysfunction as well as other symptoms such as arm, breast, and neck swelling. Treatment options for both peripheral and central venous stenoses include plain old balloon angioplasty, angioplasty with drug-coated balloons, and stenting. This article discusses the current evidence for the use of drug-coated balloon angioplasty in this patient population.
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Affiliation(s)
- Panagiotis Kitrou
- Department of Interventional Radiology, Patras University Hospital, Patras, Greece,Address for correspondence Panagiotis Kitrou, MD Department of Interventional Radiology, Patras University HospitalPatras 26500Greece
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16
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Luo C, Liang M, Liu Y, Zheng D, He Q, Jin J. Paclitaxel coated balloon versus conventional balloon angioplasty in dysfunctional dialysis arteriovenous fistula: a systematic review and meta-analysis of randomized controlled trials. Ren Fail 2022; 44:155-170. [PMID: 35166168 PMCID: PMC8856055 DOI: 10.1080/0886022x.2022.2029487] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Purpose To compare the efficacy and safety between paclitaxel coated balloon (PCB) angioplasty and conventional balloon (CB) angioplasty in the treatment of dysfunctional arteriovenous fistula (AVF). Methods We searched four major electronic databases (PubMed, EMBASE, Web of Science and the Cochrane Library) for randomized controlled trials (RCTs) published from inception through November 28, 2021. Outcomes of interest included target lesion primary patency (TLPP), technical success and all-cause mortality. The STATA package version 15.1 was utilized to undertake meta-analyses. Results Fourteen RCTs totaling 1535 patients were analyzed. The available data showed that there were no significant differences of TLPP rates at 3, 6, 9 and 12 months between the PCB group and the CB group (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.93–1.07, p = 1.000, I2 = 33.5%, Cochrane Q test p = 0.185, fixed-effect model; RR 1.17, 95% CI 0.99–1.39, p = 0.065, I2 = 75.4%, Cochrane Q test p = 0.000, random-effect model; RR 0.81, 95% CI 0.35–1.89, p = 0.625, I2 = 62.8%, Cochrane Q test p = 0.045, random-effect model; RR 1.19, 95% CI 0.97–1.47, p = 0.096, I2 = 40.5%, Cochrane Q test p = 0.071, random-effect model). In addition, two groups had similar technical success rates (RR 1.00, 95% CI 0.97–1.03, p = 1.000, I2 = 0.0%, Cochrane Q test p = 0.596, fixed-effect model) and all-cause mortality rates (RR 1.00, 95% CI 0.54–1.84, p = 1.000, I2 = 0.0%, Cochrane Q test p = 0.599, fixed-effect model). Conclusions PCB angioplasty did not appear to convey any obvious advantage over CB angioplasty in the treatment of dysfunctional AVF. However, further multi-center, large-scale and well-designed RCTs are needed to prove outcomes.
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Affiliation(s)
- Chuxuan Luo
- Division of Health Sciences, Hangzhou Normal University, Hangzhou, Zhejiang, China.,Department of Nephrology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Mingzhu Liang
- Department of Nephrology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China.,The Medical College of Qingdao University, Qingdao, Shandong, China
| | - Yueming Liu
- Department of Nephrology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Danna Zheng
- Department of Nephrology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Qiang He
- Department of Nephrology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Juan Jin
- Department of Nephrology, the First People's Hospital of Hangzhou Lin'an District, Affiliated Lin'an People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
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17
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Spiliopoulos S, Giannikouris IE, Katsanos K, Filippou P, Efthymiou E, Reppas L, Kitrou P, Palialexis K, Filippiadis D, Brountzos E. VOLume flow assistance for optimizing outcomes of dysfunctional autologous arteriovenous fistula Angioplasty: the VOLA Pilot Study. Eur Radiol 2022; 32:368-376. [PMID: 34195887 DOI: 10.1007/s00330-021-08139-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 06/01/2021] [Accepted: 06/06/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To investigate the feasibility of VF-assisted angioplasty (VFA) in dysfunctional AVF using sequential intraprocedural duplex ultrasound (DUS), to utilize intraprocedural VF as a quantifiable, functional endpoint in endovascular treatment. METHODS This prospective study included 20 consecutive patients (23 lesions; 16 men; mean age 67 ± 16 years) with dysfunctional AVF undergoing fluoroscopically guided balloon angioplasty between June 2019 and May 2020. Primary endpoints were quantification of outcome using sequential DUS VF analysis following each dilation, 6-month target lesion re-intervention (TLR)-free rate, standard technical success, procedural success (achievement of a postprocedural VF value equal (or 10% less) or superior to the baseline steady-state access), and correlation between procedural success and TLR-free rate. Secondary endpoints included 6-month lesion late lumen loss (LLL), correlation between balloon diameter used and intraprocedural VF values, and correlation between VF and LLL at 6 months follow-up. RESULTS Mean VF increase was 168.5% ± 102.5% (range: 24.24-493.33%). Procedural success was 80% (16/20 cases). VFA improved procedural success by 20% (4/20 cases) compared to standard assessment (< 30% residual stenosis and palpable thrill). TLR-free rate was 78.3% and 67.3% at 6 and 12 months. Significantly less TLR was noted in cases of procedural success (82.4% vs. 66.7% 6 months; p = 0.041). Unweighted linear regression showed a significant positive relationship between diameter of balloon and VF (146.9 ± 42.3 mL/min VF gain per mm of balloon diameter; p = 0.001, R2 = 0.23) and a significant negative relationship between LLL and VF decline at follow-up (102.0 ± 34.6 mL/min loss per mm of LLL; p = 0.01, R2 = 0.35). Optimal VF cutoff value and percentile increase to predict access failure were 720 mL/min (sensitivity 58.3%, specificity 71.4%) and 153% (sensitivity 66.7%, specificity 85.7%), respectively. CONCLUSION Intraprocedural VF assessment could be used to optimize AVF angioplasty. KEY POINTS • A newly proposed functional endpoint of angioplasty in dysfunctional dialysis fistula was evaluated and angioplasty outcome was quantified using volume flow (VF) assessment with sequential intraprocedural DUS. • Intraprocedural VF assessment improved immediate procedural success; increased balloon diameter was correlated with VF gain and late lumen loss with VF decline. • Intraprocedural VF values ≥ to baseline steady-state values were correlated with less re-interventions.
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Affiliation(s)
- Stavros Spiliopoulos
- 2nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Rimini 1st St, 12461, Chaidari, Athens, Greece.
| | | | - Konstantinos Katsanos
- Department of Interventional Radiology, School of Medicine, Patras University Hospital, Rion, Greece
| | - Panagiotis Filippou
- 2nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Rimini 1st St, 12461, Chaidari, Athens, Greece
| | - Evgenia Efthymiou
- 2nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Rimini 1st St, 12461, Chaidari, Athens, Greece
| | - Lazaros Reppas
- 2nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Rimini 1st St, 12461, Chaidari, Athens, Greece
| | - Panagiotis Kitrou
- Department of Interventional Radiology, School of Medicine, Patras University Hospital, Rion, Greece
| | - Konstantinos Palialexis
- 2nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Rimini 1st St, 12461, Chaidari, Athens, Greece
| | - Dimitrios Filippiadis
- 2nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Rimini 1st St, 12461, Chaidari, Athens, Greece
| | - Elias Brountzos
- 2nd Department of Radiology, Interventional Radiology Unit, Medical School, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Rimini 1st St, 12461, Chaidari, Athens, Greece
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18
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Pang SC, Tan RY, Choke E, Ho J, Tay KH, Gogna A, Irani FG, Zhuang KD, Toh L, Chan S, Krishnan P, Lee KA, Leong S, Lo R, Patel A, Tan BS, Too CW, Chua J, Tng RKA, Tang TY, Chng SP, Chong TT, Tay HT, Yap HY, Wong J, Dharmaraj RB, Ng JJ, Gopinathan A, Loh EK, Ong SJ, Yoong G, Tay JS, Chong KY, Tan CS. SIroliMus coated angioPlasty versus plain balloon angioplasty in the tREatment of dialySis acceSs dysfunctION (IMPRESSION): study protocol for a randomized controlled trial. Trials 2021; 22:945. [PMID: 34930401 PMCID: PMC8687634 DOI: 10.1186/s13063-021-05920-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/06/2021] [Indexed: 11/21/2022] Open
Abstract
Background Percutaneous transluminal angioplasty is the current standard treatment for arteriovenous fistula (AVF) stenosis. The mid- and long-term patency with plain balloon angioplasty (PBA) is however far from satisfactory. While paclitaxel-coated balloon angioplasty has been shown to be superior to PBA, concern over its safety profile has recently arisen after a reported possible increased mortality risk with a meta-analysis of large lower limb studies. An angioplasty balloon with a new type of drug coating, the sirolimus-coated balloon (SCB), has been proven to improve patency in the coronary arteries. However, its effect on AV access has yet to be studied. Methods/design This is an investigator-initiated, prospective, multicenter, double-blinded, randomized controlled clinical trial to assess the effectiveness of SCB compared to PBA in improving the patency of AVF after angioplasty. A total of 170 patients with mature AVF that requires PTA due to AVF dysfunction will be randomly assigned to treatment with a SCB or PBA at a 1:1 ratio, stratified by location of AVF and followed up for up to 1 year. The inclusion criteria include [1] adult patient aged 21 to 85 years who requires balloon angioplasty for dysfunctional arteriovenous fistula [2]; matured AVF, defined as being in use for at least 1 month prior to the angioplasty; and [3] successful angioplasty of the underlying stenosis with PBA, defined as less than 30% residual stenosis on digital subtraction angiography (DSA) and restoration of thrill in the AVF on clinical examination. The exclusion criteria include thrombosed or partially thrombosed access circuit at the time of treatment, presence of symptomatic or angiographically significant central vein stenosis that requires treatment with more than 30% residual stenosis post angioplasty, and existing stent placement within the AVF circuit. The primary endpoint of the study is access circuit primary patency at 6 months. The secondary endpoints are target lesion primary patency; access circuit-assisted primary patency; access circuit secondary patency at 3, 6, and 12 months; target lesion restenosis rate at 6 months; total number of interventions; complication rate; and cost-effectiveness. The trial is supported by Concept Medical. Discussion This study will evaluate the clinical efficacy and safety of SCB compared to PBA in the treatment of AVF stenosis in hemodialysis patients. Trial registration ClinicalTrials.govNCT04409912. Registered on 1 June 2020
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Affiliation(s)
- Suh Chien Pang
- Department of Renal Medicine, Singapore General Hospital, Academia, Level 3, 20 College Road, Singapore, 169856, Singapore.
| | - Ru Yu Tan
- Department of Renal Medicine, Singapore General Hospital, Academia, Level 3, 20 College Road, Singapore, 169856, Singapore
| | - Edward Choke
- Vascular and Endovascular Service, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Jackie Ho
- Department of Cardiac, Thoracic & Vascular Surgery, National University Hospital, NUHS Tower Block, Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Kiang Hiong Tay
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Apoorva Gogna
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Farah G Irani
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Kun Da Zhuang
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Luke Toh
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Shaun Chan
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Pradesh Krishnan
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Kristen A Lee
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Sum Leong
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Richard Lo
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Ankur Patel
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Bien Soo Tan
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Chow Wei Too
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Jasmine Chua
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Ren Kwang Alvin Tng
- Department of Renal Medicine, Singapore General Hospital, Academia, Level 3, 20 College Road, Singapore, 169856, Singapore
| | - Tjun Yip Tang
- Department of Vascular Surgery, Singapore General Hospital, Academia, Level 5, 20 College Road, Singapore, 169856, Singapore
| | - Siew Ping Chng
- Department of Vascular Surgery, Singapore General Hospital, Academia, Level 5, 20 College Road, Singapore, 169856, Singapore
| | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Academia, Level 5, 20 College Road, Singapore, 169856, Singapore
| | - Hsien Ts'ung Tay
- Department of Vascular Surgery, Singapore General Hospital, Academia, Level 5, 20 College Road, Singapore, 169856, Singapore
| | - Hao Yun Yap
- Department of Vascular Surgery, Singapore General Hospital, Academia, Level 5, 20 College Road, Singapore, 169856, Singapore
| | - Julian Wong
- Department of Cardiac, Thoracic & Vascular Surgery, National University Hospital, NUHS Tower Block, Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Rajesh Babu Dharmaraj
- Department of Cardiac, Thoracic & Vascular Surgery, National University Hospital, NUHS Tower Block, Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Jun Jie Ng
- Department of Cardiac, Thoracic & Vascular Surgery, National University Hospital, NUHS Tower Block, Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Anil Gopinathan
- Department of Diagnostic Imaging, National University Health System, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Eu Kuang Loh
- Department of Diagnostic Imaging, National University Health System, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Shao Jin Ong
- Department of Diagnostic Imaging, National University Health System, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Gary Yoong
- Department of Diagnostic Imaging, National University Health System, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Jia Sheng Tay
- Vascular and Endovascular Service, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Kay Yuan Chong
- Division of Medicine, Singapore General Hospital, SingHealth Tower, Level 5, Singapore, Singapore
| | - Chieh Suai Tan
- Department of Renal Medicine, Singapore General Hospital, Academia, Level 3, 20 College Road, Singapore, 169856, Singapore
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19
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Liu C, Wolfers M, Awan BEZ, Ali I, Lorenzana AM, Smith Q, Tadros G, Yu Q. Drug-Coated Balloon Versus Plain Balloon Angioplasty for Hemodialysis Dysfunction: A Meta-Analysis of Randomized Controlled Trials. J Am Heart Assoc 2021; 10:e022060. [PMID: 34796720 PMCID: PMC9075359 DOI: 10.1161/jaha.121.022060] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Both drug-coated balloon (DCB) angioplasty and conventional plain balloon angioplasty (PBA) can be implemented to treat hemodialysis dysfunction. The present study aims to compare the safety and efficacy of these 2 approaches by conducting a meta-analysis of available randomized controlled trials. Methods and Results PubMed, Cochrane Library, and Embase databases were queried from establishment to January 2021. A total of 18 randomized controlled trials including 877 and 875 patients in the DCB and PBA groups, respectively, were included in the present meta-analysis. Target lesion primary patency, circuit patency, target lesion revascularization, and mortality were pooled. Odds ratios (ORs) were reported with 95% CIs. Publication bias was analyzed with funnel plot and Egger test. Target lesion primary patency was higher among patients who underwent DCB (OR, 2.93 [95% CI, 2.13-4.03], P<0.001 at 6 months; OR, 2.47 [95% CI, 1.53-3.99], P<0.001 at 1 year). Also, the DCB group had a higher dialysis circuit patency at 6 months (OR, 2.42; 95% CI, 1.56-3.77 [P<0.001]) and 1 year (OR, 1.91; 95% CI, 1.22-3.00 [P=0.005]). Compared with the PBA group, the DCB group had lower odds of target lesion revascularization during follow-up (OR, 0.43 [95% CI, 0.23-0.82], P=0.001 at 6 months; OR, 0.74 [95% CI, 0.32-1.73], P=0.490 at 1 year). The OR of mortality was comparable between 2 groups at 6 months (OR, 1.18; 95% CI, 0.42-3.33 [P=0.760]) and 1 year (OR, 0.93; 95% CI, 0.58-1.48 [P=0.750]). Conclusions Based on evidence from 18 randomized controlled trials, DCB angioplasty is superior to PBA in maintaining target lesion primary patency and circuit patency among patients with dialysis circuit stenosis. DCB angioplasty also reduces target lesion revascularization with a similar risk of mortality compared with PBA.
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Affiliation(s)
- Chenyu Liu
- School of Medicine and Health Sciences George Washington University Washington DC
| | - Matthew Wolfers
- Department of General Surgery Cleveland Clinic Florida Weston FL
| | - Bint-E Zainab Awan
- School of Medicine and Health Sciences George Washington University Washington DC
| | - Issa Ali
- School of Medicine and Health Sciences George Washington University Washington DC
| | | | - Quinn Smith
- College of Osteopathic Medicine Kansas City University Kansas City MO
| | - George Tadros
- Department of General Surgery Cleveland Clinic Florida Weston FL
| | - Qian Yu
- Division of Interventional Radiology Department of Radiology University of Chicago Chicago IL
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20
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Hu H, Tan Q, Wang J, Liu Y, Yang Y, Zhao J. Drug-coated balloon angioplasty for failing haemodialysis access: meta-analysis of randomized clinical trials. Br J Surg 2021; 108:1293-1303. [PMID: 34595522 PMCID: PMC10364885 DOI: 10.1093/bjs/znab301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/09/2021] [Accepted: 07/25/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Arteriovenous fistulas, a major treatment for end-stage kidney disease, frequently require endovascular reinterventions to maintain haemodialysis function. Drug-coated angioplasty balloons (DCBs) were developed with the intention of reducing reintervention rates. The aim of this study was to perform a systematic review and meta-analysis of DCBs in the treatment of failing haemodialysis access. METHODS Electronic databases were searched systematically to identify all relevant RCTs and any follow-up studies from RCTs. Pooled estimates of dichotomous outcomes were calculated using the odds ratio (OR) and 95 per cent confidence interval. Effect data are presented as summary hazard ratio and 95 per cent confidence interval. RESULTS Some 19 studies from 18 RCTs and comprising 1898 patients were included in the meta-analysis. Compared with plain balloon angioplasty (PBA), DCB use was associated with higher target-lesion primary patency (HR 0.60, 95 per cent c.i. 0.45 to 0.79), access-circuit primary patency (HR 0.67, 0.56 to 0.80), and less target-lesion revascularization (TLR) within 6 months (OR 0.33, 0.23 to 0.47). No difference was observed between DCB and PBA in 12-month TLR (OR 0.62, 0.28 to 1.37). Mortality after DCB use was similar to that associated with PBA use at 6 months (OR 1.20, 0.65 to 2.21) and 12 months (OR 0.99, 0.66 to 1.49), and was higher at 24 months (23.1 versus 16.6 per cent), although the difference was not statistically significant (OR 1.53, 0.92 to 2.53). CONCLUSION Drug-coated balloon angioplasty of haemodialysis fistulas is associated with higher patency rates and lower rates of reintervention in the short to mid term. Although mortality rates appeared to be higher with drug-coated angioplasty at 24 months, this did not reach statistical significance.
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Affiliation(s)
- H Hu
- Department of Vascular Surgery and National Clinical Research Centre for Geriatrics, West China of Sichuan University Hospital, Chengdu, China
| | - Q Tan
- Department and Laboratory of Integrated Traditional Chinese and Western Medicine, Sichuan Provincial Pancreatitis Centre and West China-Liverpool Biomedical Research Centre, West China Hospital of Sichuan University, Chengdu, China
| | - J Wang
- Department of Vascular Surgery and National Clinical Research Centre for Geriatrics, West China of Sichuan University Hospital, Chengdu, China
| | - Y Liu
- Department of Vascular Surgery and National Clinical Research Centre for Geriatrics, West China of Sichuan University Hospital, Chengdu, China
| | - Y Yang
- Department of Vascular Surgery and National Clinical Research Centre for Geriatrics, West China of Sichuan University Hospital, Chengdu, China
| | - J Zhao
- Department of Vascular Surgery and National Clinical Research Centre for Geriatrics, West China of Sichuan University Hospital, Chengdu, China
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21
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Han A, Park T, Kim HJ, Min S, Ha J, Min SK. Editor's Choice - Paclitaxel Coated Balloon Angioplasty vs. Plain Balloon Angioplasty for Haemodialysis Arteriovenous Access Stenosis: A Systematic Review and a Time to Event Meta-Analysis of Randomised Controlled Trials. Eur J Vasc Endovasc Surg 2021; 62:597-609. [PMID: 34420890 DOI: 10.1016/j.ejvs.2021.05.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 05/18/2021] [Accepted: 05/30/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE A systematic review and meta-analysis of randomised controlled trials (RCTs) was performed to determine the effectiveness and safety of drug coated balloon (DCB) angioplasty compared with uncoated plain balloon (PB) angioplasty in treating arteriovenous access stenosis. METHODS MEDLINE, Embase, Scopus, and the Cochrane Central Register of Controlled Trials were searched for RCTs comparing paclitaxel coated DCB and PB angioplasty for arteriovenous access stenosis. The last date of the literature search was 31 December 2020. Risk of bias of the retrieved studies was assessed with the Cochrane Collaboration tool for assessing risk of bias (RoB 2.0). The random effects model was used to estimate the risk of loss of target lesion patency (six and 12 months) and circuit patency (six and 12 months). Procedure related adverse events and mortality rate were also compared. Patency results were pooled using the time to event meta-analytical method and the quality of evidence was assessed according to the GRADE approach. RESULTS Sixteen eligible trials, including 1 682 lesions, were included in the quantitative analysis for the efficacy and safety of paclitaxel coated DCBs. DCBs were associated with a lower risk of loss of target lesion patency at six months (HR 0.53, 95% CI 0.42 - 0.66) and 12 months (HR 0.60, 95% CI 0.47 - 0.76), and were also associated with improved six and 12 month circuit patency. Overall quality of evidence was moderate to low. Procedural complications were rare, and the risk of death up to 12 months was similar between the two groups (OR 1.03, 95% CI 0.68 - 1.56). CONCLUSION Paclitaxel coated DCBs reduced the risk of loss of target lesion patency and circuit patency in arteriovenous access stenosis compared with PBs. Considering the heterogeneity of the included trials, there is a need to investigate optimal treatment regimens regarding drug dose and agent of the DCB and the treatment procedure.
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Affiliation(s)
- Ahram Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea.
| | - Taejin Park
- Department of Surgery, Gyeongsang National University School of Medicine, Jinju, South Korea.
| | - Hyun Jung Kim
- Institute for Evidence Based Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Sangil Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Seung-Kee Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea.
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22
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Fong KY, Zhao JJ, Tan E, Syn NL, Sultana R, Zhuang KD, Chua JME, Patel A, Irani FG, Tay KH, Tan BS, Too CW. Drug Coated Balloons for Dysfunctional Haemodialysis Venous Access: A Patient Level Meta-Analysis of Randomised Controlled Trials. Eur J Vasc Endovasc Surg 2021; 62:610-621. [PMID: 34362627 DOI: 10.1016/j.ejvs.2021.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 03/26/2021] [Accepted: 06/04/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To perform an individual patient data level meta-analysis of randomised controlled trials comparing drug coated balloon angioplasty (DCB) against conventional percutaneous transluminal angioplasty (PTA) in the treatment of dysfunctional haemodialysis venous access. METHODS A search was conducted from inception to 13 November 2020. Kaplan-Meier curves comparing DCB with PTA by target lesion primary patency (TLPP) and access circuit primary patency (ACPP) were graphically reconstructed to retrieve patient level data. One stage meta-analyses with Cox models with random effects shared frailties were conducted to determine hazard ratios (HRs). Dynamic restricted mean survival times (RMST) were conducted in view of violation of the proportional hazards assumption. Conventional two stage meta-analyses and network meta-analyses under random effects Frequentist models were conducted to determine overall and comparative outcomes of paclitaxel concentrations used. Where outliers were consistently detected through outlier and influence analyses, sensitivity analyses excluding those studies were conducted. RESULTS Among 10 RCTs (1 207 patients), HRs across all models favoured DCB (one stage shared frailty HR 0.62, 95% CI 0.53 - 0.73, p < .001; two stage random effects HR 0.60, 95% CI 0.42 - 0.86, p = .018, I2 = 65%) for TLPP. Evidence of time varying effects (p = .005) was found. TLPP RMST was + 3.54 months (25.0%) longer in DCB treated patients compared with PTA (p = .001) at three years. TLPP at six months, one year, and two years was 75.3% vs. 58.1%, 51.1% vs. 37.1%, and 31.4% vs. 26.0% for DCB and PTA, respectively. The P-Scores within the Frequentist network meta-analysis suggest that higher concentrations of paclitaxel were associated with better TLPP and ACPP. Among six RCTs (854 patients), the one stage model favoured DCB (shared frailty HR 0.72, 95% CI 0.60 - 0.87, p < .001) for ACPP. Conversely, the two stage random effects model demonstrated no significant difference (HR 0.76, 95% CI 0.35 - 1.67, p = .41, I2 = 81%). Sensitivity analysis excluding outliers significantly favoured DCB (HR 0.61, 95% CI 0.41 - 0.91, p = .027, I2 = 62%). CONCLUSION Overall evidence suggests that DCB is favoured over PTA in TLPP and ACPP.
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Affiliation(s)
- Khi Yung Fong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Joseph J Zhao
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Eelin Tan
- Department of Vascular & Interventional Radiology, Singapore General Hospital, Singapore; Division of Radiological Sciences, Singapore General Hospital, Singapore; Radiological Sciences Academic Clinical Program, SingHealth-Duke-NUS Academic Medical Centre, Singapore
| | - Nicholas L Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Rehena Sultana
- Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore
| | - Kun Da Zhuang
- Department of Vascular & Interventional Radiology, Singapore General Hospital, Singapore; Division of Radiological Sciences, Singapore General Hospital, Singapore; Radiological Sciences Academic Clinical Program, SingHealth-Duke-NUS Academic Medical Centre, Singapore
| | - Jasmine Ming Er Chua
- Department of Vascular & Interventional Radiology, Singapore General Hospital, Singapore; Division of Radiological Sciences, Singapore General Hospital, Singapore; Radiological Sciences Academic Clinical Program, SingHealth-Duke-NUS Academic Medical Centre, Singapore
| | - Ankur Patel
- Department of Vascular & Interventional Radiology, Singapore General Hospital, Singapore; Division of Radiological Sciences, Singapore General Hospital, Singapore; Radiological Sciences Academic Clinical Program, SingHealth-Duke-NUS Academic Medical Centre, Singapore
| | - Farah G Irani
- Department of Vascular & Interventional Radiology, Singapore General Hospital, Singapore; Division of Radiological Sciences, Singapore General Hospital, Singapore; Radiological Sciences Academic Clinical Program, SingHealth-Duke-NUS Academic Medical Centre, Singapore
| | - Kiang Hiong Tay
- Department of Vascular & Interventional Radiology, Singapore General Hospital, Singapore; Division of Radiological Sciences, Singapore General Hospital, Singapore; Radiological Sciences Academic Clinical Program, SingHealth-Duke-NUS Academic Medical Centre, Singapore
| | - Bien Soo Tan
- Department of Vascular & Interventional Radiology, Singapore General Hospital, Singapore; Division of Radiological Sciences, Singapore General Hospital, Singapore; Radiological Sciences Academic Clinical Program, SingHealth-Duke-NUS Academic Medical Centre, Singapore
| | - Chow Wei Too
- Department of Vascular & Interventional Radiology, Singapore General Hospital, Singapore; Division of Radiological Sciences, Singapore General Hospital, Singapore; Radiological Sciences Academic Clinical Program, SingHealth-Duke-NUS Academic Medical Centre, Singapore.
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23
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Jaffer O, Gibbs P, Gibson M, Gilbert J, Hanko J, Jeevaratnam P, Jones R, Nicholas J, Ramnarine R, Sivaprakasam R, Steiner K, Tippett R, Wilkins J. A UK Expert Consensus Approach for Managing Symptomatic Arteriovenous Fistula (AVF) Stenosis in Haemodialysis Patients. Cardiovasc Intervent Radiol 2021; 44:1736-1746. [PMID: 34231014 DOI: 10.1007/s00270-021-02875-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 05/17/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Stenoses in mature arteriovenous fistulas (AVFs) are common and can negatively impact on the quality of haemodialysis, the longevity of the AVF and lead to debilitating symptoms. Multiple treatment options exist; however, management can vary between different centres. We aimed to establish multidisciplinary consensus on the optimal stepwise application of interventions based on evidence and consensus. METHODS A modified Delphi process was conducted with 13 participants from hospitals across the UK, all of whom have high-volume dialysis access practice. RESULTS The usual intervention to rectify de novo stenoses of mature AVFs is fistuloplasty, although surgery for inflow segment stenoses is also clinically acceptable. Appropriate first-line interventions include plain old balloon angioplasty or high-pressure balloon angioplasty; if these fail during the fistuloplasty, consider upsizing the balloon, prolonged balloon inflation or using alternative interventions, such as cutting or scoring balloons and ultra-high-pressure balloons. Alternative or subsequent interventions vary by anatomical site and may require additional multidisciplinary team input. For a stenoses recurring between 3 and 12 months, it is appropriate to consider interventions used de novo, but with a lower threshold for using drug-coated balloons (DCBs) in all regions and for using stent grafts in all regions but inflow segment. Recurrence after 12 months should be treated as a de novo lesion, with DCBs considered if they have been used successfully during previous interventions. CONCLUSIONS These recommendations aim to provide a practical guide to multidisciplinary teams in order to optimise the use of multiple interventions for rectifying AVF stenoses and provide unified evidence-based practice guidelines.
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Affiliation(s)
- Ounali Jaffer
- Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, Whitechapel, London, E1 1BB, UK.
| | - Paul Gibbs
- Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Matthew Gibson
- Royal Berkshire Hospital, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - James Gilbert
- Oxford Transplant Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jennifer Hanko
- Belfast City Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | | | - Robert Jones
- University Hospital Birmingham, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Johann Nicholas
- Royal Shrewsbury Hospital, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - Raymond Ramnarine
- Gloucestershire Royal Hospital, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Rajesh Sivaprakasam
- Royal London Hospital, Barts Health NHS Trust, Whitechapel Road, Whitechapel, London, E1 1BB, UK
| | - Kate Steiner
- Lister Hospital, East and North Herts NHS Trust, Stevenage, UK
| | - Richard Tippett
- Dorset County Hospital, Dorset County Hospital NHS Foundation Trust, Dorchester, UK
| | - Jason Wilkins
- King's College Hospital NHS Foundation Trust, London, UK
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Kitrou PM, Steinke T, El Hage R, Ponce P, Lucatelli P, Katsanos K, Spiliopoulos S, Spinelli A, Bisdas T, Stavroulakis K, Jaffer O, Mallios A, Zilahi de Gyurgyokai S, Cancellieri R, Coscas R, Karnabatidis D. Paclitaxel-Coated Balloons for the Treatment of Symptomatic Central Venous Stenosis in Vascular Access: Results From a European, Multicenter, Single-Arm Retrospective Analysis. J Endovasc Ther 2021; 28:442-451. [PMID: 33834905 DOI: 10.1177/15266028211007471] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION This was a European, multicenter, investigator-initiated and run, single-arm retrospective analysis to assess the safety and the clinical benefit of the use of paclitaxel-coated balloon (PCB) for the treatment of symptomatic central venous stenosis (CVS). MATERIALS AND METHODS Eleven centers from 7 countries across Europe, submitted 86 cases performed during the period between October 2015 and June 2018. Minimum follow-up was 6 months. Patient baseline demographics and procedural details were collected. Mean age was 62.6 years (SD 15.2 years). Median vascular access age was 3.0 years (IQR 1.2-4.8 years). A total of 55 were arteriovenous fistulas (64%) the rest arteriovenous grafts (31/86, 36%). Vessels treated were 43 subclavian veins, 42 brachiocephalic veins and 1 superior vena cava. Median drug-coated balloon diameter was 10 mm (IQR 8-12 mm). Primary outcome measures were clinically assessed intervention-free period (IFP) of the treated segment at 6 months and procedure-related minor and major complications. Secondary outcome measures included access circuit survival, patient survival, and the investigation of independent factors that influence the IFP. RESULTS IFP was 62.7% at 6 months. Median patient follow-up time was 1.0 year (IQR 0.5-2.2 years). There was 1 minor complication (1/86; 1.2%) and no major complications. Access circuit survival was 87.7% at 6 months. Patient survival was 79.7% at 2 years according to Kaplan-Meier survival analysis. Higher balloon diameters significantly favored IFP [HR 0.71 (0.55-0.92), p=0.006; 5-7 mm group vs 8-12 mm group, p=0.025]. CONCLUSION In this analysis, use of PCBs for the treatment of symptomatic CVS was safe. Efficacy was comparable to previous trials. Increased balloon size had a significant effect on patency rates.
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Affiliation(s)
| | - Tobias Steinke
- Fachzentrum für Gefäßchirurgie, Schön Klinik Düsseldorf SE & Co. KG, Düsseldorf, Germany
| | - Rami El Hage
- Vasular Surgery, Paris Saint Joseph Hospital, Paris, France
| | - Pedro Ponce
- Fresenius Medical Care Portugal/Nephrocare, Lisbon, Portugal
| | - Pierleone Lucatelli
- Vascular and Interventional Radiology Unit, Department of Radiological Oncological and Anatomopathological Sciences, Sapienza University of Rome, Italy
| | | | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, School of Medicine, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens, Greece
| | - Alessio Spinelli
- U.O.S.D. of Interventional Radiology, Hospital "S. Eugenio" Rome, ASL Roma, Italy
| | - Theodosios Bisdas
- Third Clinic of Vascular Surgery, Athens Medical Center, Athens, Greece
| | - Konstantinos Stavroulakis
- Department of Vascular and Endovascular Surgery, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Ounali Jaffer
- Department of Diagnostic and International Radiology, Barts NHS Trust, Royal London Hospital, London, UK
| | | | - Simone Zilahi de Gyurgyokai
- Vascular and Interventional Radiology Unit, Department of Radiological Oncological and Anatomopathological Sciences, Sapienza University of Rome, Italy
| | - Roberto Cancellieri
- Vascular and Interventional Radiology Unit, Department of Radiological Oncological and Anatomopathological Sciences, Sapienza University of Rome, Italy
| | - Raphael Coscas
- Department of Vascular Surgery, Ambroise Paré University Hospital, Boulogne-Billancourt, France
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Lazarides MK, Christaina E, Antoniou GA, Argyriou C, Trypsianis G, Georgiadis GS. Plain versus paclitaxel-coated balloon angioplasty in arteriovenous fistula and graft stenosis: An umbrella review. J Vasc Access 2021; 23:981-988. [PMID: 34058909 DOI: 10.1177/11297298211005290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
An umbrella review was performed to synthesize the evidence from systematic reviews/meta-analyses of clinical trials investigating the efficacy and safety of paclitaxel-coated balloons (PCB) vs. conventional balloon angioplasty in arteriovenous fistulas (AVFs) and grafts stenosis.Medline (via PubMed) and SCOPUS databases were searched up to July 15th 2020. All meta-analyses that enrolled randomized controlled trials (RCTs) comparing PCB with plain balloons in AVFs and grafts were included. Re-analysis of original data was performed assessing predictive intervals (PI). Quality of the included meta-analyses was assessed using AMSTAR score. Eight meta-analyses were included and four clinical outcomes [target lesion primary patency (TLPP), circuit primary patency, mortality, complication rate] derived from 14 RCTs, were analyzed. There were no significant differences in the TLPP in meta-analyses providing data purely from autologous AVFs. Significant benefits regarding TLPP and circuit primary patency at 3, 6, and 12-months in favor of PCB were reported in four meta-analyses mixing AVFs and grafts; however when PI were assessed, in all but one meta-analysis these included the null value, indicating no significant benefit. In only one meta-analysis significant difference of TLPP at 12-months in favor of PCB was noticed. (Odds Ratio 0.0009 PI: 0.28-0.85) No mortality difference was noticed in four meta-analyses providing data up to 24 months. In conclusion this overview revealed a modest benefit of using PCB angioplasty compared to plain angioplasty in AVFs and graft stenosis. No increased mortality was noticed in the PCB group.
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Affiliation(s)
- Miltos K Lazarides
- Department of Vascular Surgery, Democritus University, Alexandroupolis, Greece
| | - Eleni Christaina
- Department of Biostatistics, Democritus University, Alexandroupolis, Greece
| | - George A Antoniou
- Department of Vascular & Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, University of Manchester, Manchester, UK
| | - Christos Argyriou
- Department of Vascular Surgery, Democritus University, Alexandroupolis, Greece
| | - Gregory Trypsianis
- Department of Biostatistics, Democritus University, Alexandroupolis, Greece
| | - George S Georgiadis
- Department of Vascular Surgery, Democritus University, Alexandroupolis, Greece
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26
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Kitrou PM, Katsanos K, Karnabatidis D. New Evidence to Support the Use of Drug Coated Balloons in the Treatment of Dysfunctional Vascular Access. Eur J Vasc Endovasc Surg 2021; 61:540-541. [PMID: 33602546 DOI: 10.1016/j.ejvs.2021.01.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/08/2020] [Accepted: 01/13/2021] [Indexed: 01/16/2023]
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27
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Karnabatidis D, Kitrou PM, Ponce P, Chong TT, Pietura R, Pegis JD, Ko PJ, Lin CH. A Multicenter Global Registry of Paclitaxel Drug-Coated Balloon in Dysfunctional Arteriovenous Fistulae and Grafts: 6-Month Results. J Vasc Interv Radiol 2021; 32:360-368.e2. [PMID: 33495064 DOI: 10.1016/j.jvir.2020.11.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 10/22/2022] Open
Abstract
PURPOSE To assess the safety and clinical benefit of the Lutonix drug-coated balloon (DCB) catheter for the treatment of dysfunctional arteriovenous fistulae (AVF) and grafts (AVG) in a heterogenous real-world population. MATERIALS AND METHODS This multicenter, prospective study enrolled 320 subjects from 12 countries in 25 sites across Europe and Asia. A total of 392 lesions were treated with the Lutonix 035 DCB catheter. Lesions were de novo and restenotic, located in every part of the circuit from the cannulation zone to central venous outflow. In-stent restenotic lesions also were treated. The primary safety endpoint was freedom from serious adverse events involving the access circuit through 30 days. The primary effectiveness endpoint was target lesion primary patency (TLPP) through 6 months. Secondary endpoints included access circuit primary patency (ACPP) at 6 months and the investigation of factors that would independently influence the primary endpoints. RESULTS The primary safety endpoint was 95.5%, while TLPP was 73.9% at 6 months, per Kaplan-Meier survival analysis. ACPP was 71% at 6 months. TLPP for stenosis of AVFs was 78.1%. Subgroup analysis showed significantly improved TLPP when DCB was dilated for ≥120 seconds (P = .007). TLPP was significantly better when predilation occurred compared with cases where only DCB angioplasty was performed (77% vs 48.6%, P = .0005). CONCLUSIONS The Lutonix AV Global Registry confirms that the Lutonix DCB is a safe and effective treatment option in real-world patients with dysfunctional AVF or AVG. Procedural details had a significant role in TLPP. No significant difference in TLPP was observed among different treatment areas.
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Affiliation(s)
| | - Panagiotis M Kitrou
- Interventional Radiology Department, Patras University Hospital, Patras, Greece.
| | - Pedro Ponce
- Fresenius Medical Care Portugal/NephroCare, Lisbon, Portugal
| | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
| | | | | | - Po-Jen Ko
- Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chia Hsun Lin
- Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
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Therasse E, Caty V, Gilbert P, Giroux MF, Perreault P, Bouchard L, Oliva VL, Lespérance J, Ethier J, Ouellet G, Francoeur M, Cournoyer S, Soulez G. Safety and Efficacy of Paclitaxel-Eluting Balloon Angioplasty for Dysfunctional Hemodialysis Access: A randomized trial Comparing with Angioplasty Alone. J Vasc Interv Radiol 2021; 32:350-359.e2. [PMID: 33483226 DOI: 10.1016/j.jvir.2020.10.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 10/26/2020] [Accepted: 10/28/2020] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To assess whether angioplasty of hemodialysis access (HA) stenosis with a drug-coated balloon (DCB) would prevent restenosis in comparison with plain-balloon percutaneous transluminal angioplasty (PTA). MATERIALS AND METHODS This prospective randomized clinical trial enrolled 120 patients with dysfunctional arteriovenous fistulae (n = 109) and grafts (n = 11), due to a ≥50% stenosis between March 2014 and April 2018. All patients underwent high-pressure balloon angioplasty and were then randomized to either DCB (n = 60) or PTA (n = 60). Patients were followed-up for 1 year, and angiography was performed 6 months after angioplasty. The primary endpoint was the late lumen loss (LLL) at 6 months. Secondary endpoints included other angiographic parameters at 6 months and HA failures, adverse event, and mortality at 12 months. Continuous variables were compared with a Student t-test, and Kaplan-Meier curves were used for freedom from HA failure and for mortality. RESULTS LLL in the DCB and in the PTA group were 0.64 mm ± 1.20 and 1.13 mm ± 1.51, respectively (P = .082, adjusted P = .0498). DCB was associated with lower percentage stenosis (54.2% ± 19.3 vs 61.7% ± 18.2; P = .047) and binary restenosis ≥50% (56.5% vs 81.1%; P = .009) than PTA. The number of HA failures after 12 months was lower for DCB than for PTA (45% vs 66.7%; P = .017). Mortality at 12 months was 10% and 8.3% in the DCB and PTA groups, respectively (P = .75). CONCLUSIONS Despite LLL improvement that failed to reach statistical significance, this study demonstrated decreased incidence and severity of restenosis with DCB compared with PTA to treat dysfunctional HA.
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Affiliation(s)
- Eric Therasse
- Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Canada; Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada.
| | | | - Patrick Gilbert
- Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Marie-France Giroux
- Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Pierre Perreault
- Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Louis Bouchard
- Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Vincent L Oliva
- Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | | | - Jean Ethier
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | | | - Martin Francoeur
- Department of Radiology, Charles Lemoyne Hospital, Greenfield Park, Canada
| | - Serge Cournoyer
- Department of Medicine, Charles Lemoyne Hospital, Greenfield Park, Canada
| | - Gilles Soulez
- Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montreal, Canada; Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
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Yin Y, Shi Y, Cui T, Li H, Chen J, Zhang L, Yu Z, Li H, Yan Y, Wu K, Jin Q. Efficacy and Safety of Paclitaxel-Coated Balloon Angioplasty for Dysfunctional Arteriovenous Fistulas: A Multicenter Randomized Controlled Trial. Am J Kidney Dis 2021; 78:19-27.e1. [PMID: 33418016 DOI: 10.1053/j.ajkd.2020.11.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 11/15/2020] [Indexed: 02/08/2023]
Abstract
RATIONALE & OBJECTIVE Previous studies have illustrated the potential superiority of drug-coated balloons (DCBs) in maintaining patency after initial angioplasty for arteriovenous fistula (AVF) dysfunction due to stenosis. Our trial evaluated the efficacy and safety of DCBs for preventing fistula restenosis in Chinese hemodialysis patients. STUDY DESIGN Multicenter, prospective, randomized, open-label, blinded end point, controlled trial. SETTINGS & PARTICIPANTS A total of 161 hemodialysis patients with fistula dysfunction from 10 centers in China. INTERVENTION Participants were randomized 1:1 to treatment with initial dilation followed by DCB angioplasty or conventional high-pressure balloon (HPB) angioplasty. OUTCOMES The primary end point was target lesion primary patency defined as the target lesion intervention-free survival in conjunction with an ultrasonography-measured peak systolic velocity ratio (PSVR) ≤2.0 at 6 months. The secondary end points included 1) device, technical, clinical, and procedural success; 2) major adverse events; 3) degree of target lesion stenosis at 6 months; and 4) clinically driven target lesion and target shunt revascularization within 12 months. RESULTS The percentage with target lesion primary patency as defined by a PSVR ≤2.0 was higher in the DCB group than in the control group (65% vs 37%, respectively; rate difference, 28% [95% CI, 13%-43%]; P <0.001) at 6 months. The target lesion and target shunt intervention-free survival of the DCB group were not superior to those of the control group at 6 months (P = 0.3 and P = 0.2, respectively) but were superior at 12 months (target lesion intervention-free survival: 73% for DCB vs 58% for control [P = 0.04]; target shunt intervention-free survival: 73% for DCB vs 57% for control [P = 0.04]). The average degree of target lesion stenoses at 6 months was not significantly different between the 2 groups (44% ± 16% for DCB vs 49% ± 18% for control; P = 0.09). There were no significant differences in major adverse events or in device, technical, clinical, or procedural success rates between the groups. LIMITATIONS Small sample size; short follow-up period; procedural differences between the 2 groups such as unequal inflation times and balloon lengths. CONCLUSIONS Compared to conventional HPB angioplasty, DCB treatment achieved superior primary patency defined using PSVR measured at 6 months and superior intervention-free survival of both the target lesion and the target shunt at 12 months without evidence of greater adverse events. FUNDING Funded by ZhuHai Cardionovum Medical Device Co., Ltd. TRIAL REGISTRATION Registered at ClinicalTrials.gov with study number NCT02962141.
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Affiliation(s)
- Yanqi Yin
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Yaxue Shi
- Department of Vascular Surgery, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Tianlei Cui
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hua Li
- Department of Nephrology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jianghua Chen
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Lihong Zhang
- Nephrology Department, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Zhengya Yu
- Department of General and Vascular Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Hong Li
- Blood Purification Center, Hainan General Hospital, Haikou, Hainan, China
| | - Yan Yan
- Department of Nephrology, First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Kun Wu
- Blood Purification Center, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Qizhuang Jin
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.
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Tripsianis G, Christaina E, Argyriou C, Georgakarakos E, Georgiadis GS, Lazarides MK. Network meta-analysis of trials comparing first line endovascular treatments for arteriovenous fistula stenosis. J Vasc Surg 2020; 73:2198-2203.e3. [PMID: 33385504 DOI: 10.1016/j.jvs.2020.12.080] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 12/10/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We investigated the comparative effectiveness of different endovascular treatments for patients with failing autogenous arteriovenous fistulas (AVFs) with outflow vein stenosis. METHODS The Medline (via PubMed) and SCOPUS databases were searched. We performed a systematic review and network meta-analysis of randomized controlled trials that had investigated the effectiveness of plain balloon angioplasty (PBA), cutting balloon angioplasty, and drug-coated balloon angioplasty (DCBA) to treat vein stenoses in autogenous AVFs. Studies of central vein stenosis were excluded. The main outcome measures were the failure rates at 6 months and 1 year after treatment. RESULTS Eleven randomized controlled trials were included, with 814 patients, 395 of whom had undergone PBA. The network meta-analysis showed that DCBA at 6 months was significantly more effective than PBA (odds ratio, 0.39; 95% confidence interval, 0.18-0.81) and ranked as the best treatment option, although the difference was not statistically significant compared with cutting balloon angioplasty (odds ratio, 0.65; 95% confidence interval, 0.20-2.12). The differences among the three treatments at 1 year were not statistically significant. Additional conventional pairwise meta-analyses did not find significant differences at 1 year. CONCLUSIONS In failing AVFs with outflow stenosis, DCBA was significantly superior to PBA, with improved 6-month failure rates. However the effectiveness of DCBA in the long term deserves further investigation.
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Affiliation(s)
- Gregory Tripsianis
- Department of Biostatistics, Democritus University Medical School, Alexandroupolis, Greece
| | - Eleni Christaina
- Department of Biostatistics, Democritus University Medical School, Alexandroupolis, Greece
| | - Christos Argyriou
- Department of Vascular Surgery, Democritus University Medical School, Alexandroupolis, Greece
| | | | - George S Georgiadis
- Department of Vascular Surgery, Democritus University Medical School, Alexandroupolis, Greece
| | - Miltos K Lazarides
- Department of Vascular Surgery, Democritus University Medical School, Alexandroupolis, Greece.
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Trerotola SO, Roy-Chaudhury P, Saad TF. Drug-Coated Balloons in Dysfunctional Arteriovenous Fistulas: Is it Time? Am J Kidney Dis 2020; 77:820-822. [PMID: 33276039 DOI: 10.1053/j.ajkd.2020.10.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/19/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Scott O Trerotola
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | | | - Theodore F Saad
- Section of Renal and Hypertensive Diseases, Christiana Care Health System, Newark, DE
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Lookstein RA, Haruguchi H, Ouriel K, Weinberg I, Lei L, Cihlar S, Holden A. Drug-Coated Balloons for Dysfunctional Dialysis Arteriovenous Fistulas. N Engl J Med 2020; 383:733-742. [PMID: 32813949 DOI: 10.1056/nejmoa1914617] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Standard percutaneous transluminal angioplasty is the current recommended treatment for dysfunctional hemodialysis fistulas, yet long-term outcomes of this treatment are poor. Drug-coated balloons delivering the antirestenotic agent paclitaxel may improve outcomes. METHODS In this prospective, single-blinded, 1:1 randomized trial, we enrolled 330 participants at 29 international sites. Patients with new or restenotic lesions in native upper-extremity arteriovenous fistulas were eligible for participation. After successful high-pressure percutaneous transluminal angioplasty, participants were randomly assigned to receive treatment with a drug-coated balloon or a standard balloon. The primary effectiveness end point was target-lesion primary patency, defined as freedom from clinically driven target-lesion revascularization or access-circuit thrombosis during the 6 months after the index procedure. The primary safety end point, serious adverse events involving the arteriovenous access circuit within 30 days, was assessed in a noninferiority analysis (margin of noninferiority, 7.5 percentage points). The primary analyses included all participants with available end-point data. Additional sensitivity analyses were performed to assess the effect of missing data. RESULTS A total of 330 participants underwent randomization; 170 were assigned to receive treatment with a drug-coated balloon, and 160 were assigned to receive treatment with a standard balloon. During the 6 months after the index procedure, target-lesion primary patency was maintained more often in participants who had been treated with a drug-coated balloon than in those who had been treated with a standard balloon (82.2% [125 of 152] vs. 59.5% [88 of 148]; difference in risk, 22.8 percentage points; 95% confidence interval [CI], 12.8 to 32.8; P<0.001). Drug-coated balloons were noninferior to standard balloons with respect to the primary safety end point (4.2% [7 of 166] and 4.4% [7 of 158], respectively; difference in risk, -0.2 percentage points; 95% CI, -5.5 to 5.0; P = 0.002 for noninferiority). Sensitivity analyses confirmed the results of the primary analyses. CONCLUSIONS Drug-coated balloon angioplasty was superior to standard angioplasty for the treatment of stenotic lesions in dysfunctional hemodialysis arteriovenous fistulas during the 6 months after the procedure and was noninferior with respect to access circuit-related serious adverse events within 30 days. (Funded by Medtronic; IN.PACT AV Access Study ClinicalTrials.gov number, NCT03041467.).
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Affiliation(s)
- Robert A Lookstein
- From Icahn School of Medicine at Mount Sinai (R.A.L.) and Syntactx (K.O.), New York; Haruguchi Vascular Access Clinic, Tokyo (H.H.); VasCore, Massachusetts General Hospital, Boston (I.W.); Medtronic, Plymouth, MN (L.L., S.C.); and the Department of Radiology, Auckland Hospital, Auckland, New Zealand (A.H.)
| | - Hiroaki Haruguchi
- From Icahn School of Medicine at Mount Sinai (R.A.L.) and Syntactx (K.O.), New York; Haruguchi Vascular Access Clinic, Tokyo (H.H.); VasCore, Massachusetts General Hospital, Boston (I.W.); Medtronic, Plymouth, MN (L.L., S.C.); and the Department of Radiology, Auckland Hospital, Auckland, New Zealand (A.H.)
| | - Kenneth Ouriel
- From Icahn School of Medicine at Mount Sinai (R.A.L.) and Syntactx (K.O.), New York; Haruguchi Vascular Access Clinic, Tokyo (H.H.); VasCore, Massachusetts General Hospital, Boston (I.W.); Medtronic, Plymouth, MN (L.L., S.C.); and the Department of Radiology, Auckland Hospital, Auckland, New Zealand (A.H.)
| | - Ido Weinberg
- From Icahn School of Medicine at Mount Sinai (R.A.L.) and Syntactx (K.O.), New York; Haruguchi Vascular Access Clinic, Tokyo (H.H.); VasCore, Massachusetts General Hospital, Boston (I.W.); Medtronic, Plymouth, MN (L.L., S.C.); and the Department of Radiology, Auckland Hospital, Auckland, New Zealand (A.H.)
| | - Lanyu Lei
- From Icahn School of Medicine at Mount Sinai (R.A.L.) and Syntactx (K.O.), New York; Haruguchi Vascular Access Clinic, Tokyo (H.H.); VasCore, Massachusetts General Hospital, Boston (I.W.); Medtronic, Plymouth, MN (L.L., S.C.); and the Department of Radiology, Auckland Hospital, Auckland, New Zealand (A.H.)
| | - Stephanie Cihlar
- From Icahn School of Medicine at Mount Sinai (R.A.L.) and Syntactx (K.O.), New York; Haruguchi Vascular Access Clinic, Tokyo (H.H.); VasCore, Massachusetts General Hospital, Boston (I.W.); Medtronic, Plymouth, MN (L.L., S.C.); and the Department of Radiology, Auckland Hospital, Auckland, New Zealand (A.H.)
| | - Andrew Holden
- From Icahn School of Medicine at Mount Sinai (R.A.L.) and Syntactx (K.O.), New York; Haruguchi Vascular Access Clinic, Tokyo (H.H.); VasCore, Massachusetts General Hospital, Boston (I.W.); Medtronic, Plymouth, MN (L.L., S.C.); and the Department of Radiology, Auckland Hospital, Auckland, New Zealand (A.H.)
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Kim JW, Kim JH, Byun SS, Kang JM, Shin JH. Paclitaxel-Coated Balloon versus Plain Balloon Angioplasty for Dysfunctional Autogenous Radiocephalic Arteriovenous Fistulas: A Prospective Randomized Controlled Trial. Korean J Radiol 2020; 21:1239-1247. [PMID: 32729275 PMCID: PMC7462765 DOI: 10.3348/kjr.2020.0067] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 04/03/2020] [Accepted: 04/07/2020] [Indexed: 12/19/2022] Open
Abstract
Objective To report the mid-term results of a single-center randomized controlled trial comparing drug-coated balloon angioplasty (DBA) and plain balloon angioplasty (PBA) for the treatment of dysfunctional radiocephalic arteriovenous fistulas (RCAVFs). Materials and Methods In this prospective study, 39 patients (mean age, 62.2 years; 21 males, 18 females) with RCAVFs failing due to juxta-anastomotic stenosis were randomly assigned to undergo either both DBA and PBA (n = 20, DBA group) or PBA alone (n = 19, PBA group) between June 2016 and June 2018. Primary endpoints were technical and clinical success and target lesion primary patency (TLPP); secondary outcomes were target lesion secondary patency (TLSP) and complication rates. Statistical analysis was performed using the Kaplan-Meier product limit estimator. Results Demographic data and baseline clinical characteristics were comparable between the groups. Technical and clinical success rates were 100% in both groups. There was no significant difference between the groups in the mean duration of TLPP (DBA group: 26.7 ± 3.6 months; PBA group: 27.0 ± 3.8 months; p = 0.902) and TLSP (DBA group: 37.3 ± 2.6 months; PBA group: 40.4 ± 1.5 months; p = 0.585). No procedural or post-procedural complications were identified. Conclusion Paclitaxel-coated balloon use did not significantly improve TLPP or TLSP in the treatment of juxta-anastomotic stenosis of dysfunctional RCAVFs.
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Affiliation(s)
- Jong Woo Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Ho Kim
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea.
| | - Sung Su Byun
- Health Promotion Center, Inha University Hospital, Incheon, Korea
| | - Jin Mo Kang
- Department of Surgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Tan RY, Tan CW, Pang SC, Foo MWY, Tang TY, Gogna A, Chong TT, Tan CS. Study protocol of a pilot study on sirolimus-coated balloon angioplasty in salvaging clotted arteriovenous graft. CVIR Endovasc 2020; 3:34. [PMID: 32627114 PMCID: PMC7335758 DOI: 10.1186/s42155-020-00123-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/11/2020] [Indexed: 11/29/2022] Open
Abstract
Background In arteriovenous graft (AVG) for haemodialysis, the primary cause of failure is venous stenosis of the graft-vein junction from neointimal hyperplasia (NIH), resulting in thrombosis. While interventions to salvage clotted AVG are known to have high clinical success rates, long-term patency rates have been suboptimal. Drug-coated balloon (DCB) has been used to treat stenosed arteriovenous access in recent years with encouraging results but data on its effect in clotted AVG is unavailable. Methods This is an investigator-initiated, single-center, single-arm prospective pilot study to determine the safety and outcome of the sirolimus-coated balloon (SCB) in the salvage of thrombosed AVG. Twenty patients who undergo successful percutaneous thrombectomy will receive treatment with SCB at the graft vein junction. The patients will be followed-up for 6-months. The primary endpoint is the patency rates at 3-month while the secondary endpoints are the patency rates and the number of interventions needed to maintain patency at 6-month. Discussion Unremitting efforts have been made to prolong the patency of AV accesses over the years. DCB angioplasty combines mechanical and biological treatment for vascular stenosis. Sirolimus, being a cystostatic anti-proliferative agent, has been successfully used in coronary artery interventions. As the primary pathology of vascular stenosis in the dialysis circuit is neointimal hyperplasia, the use of sirolimus in balloon angioplasty may be effective. With this prospective study, we evaluate the efficacy and safety of SCB in patients with clotted AVG. Trial registration ClinicalTrials.gov Identifier: NCT03666208 on 11 September 2018.
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Affiliation(s)
- Ru Yu Tan
- Department of Renal Medicine, Singapore General Hospital, Academia, Level 3, 20 College Road, Singapore, 169856, Singapore.
| | - Chee Wooi Tan
- Department of Renal Medicine, Singapore General Hospital, Academia, Level 3, 20 College Road, Singapore, 169856, Singapore
| | - Suh Chien Pang
- Department of Renal Medicine, Singapore General Hospital, Academia, Level 3, 20 College Road, Singapore, 169856, Singapore
| | - Marjorie Wai Yin Foo
- Department of Renal Medicine, Singapore General Hospital, Academia, Level 3, 20 College Road, Singapore, 169856, Singapore
| | - Tjun Yip Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
| | - Apoorva Gogna
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore, Singapore
| | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore, Singapore
| | - Chieh Suai Tan
- Department of Renal Medicine, Singapore General Hospital, Academia, Level 3, 20 College Road, Singapore, 169856, Singapore
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Chen X, Liu Y, Wang J, Zhao J, Singh N, Zhang WW. A systematic review and meta-analysis of the risk of death and patency after application of paclitaxel-coated balloons in the hemodialysis access. J Vasc Surg 2020; 72:2186-2196.e3. [PMID: 32540324 DOI: 10.1016/j.jvs.2020.04.525] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 04/10/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The comparison between paclitaxel-coated balloon (PCB) angioplasty and plain balloon angioplasty (PBA) for hemodialysis (HD) access stenosis or occlusion has not been well investigated. The objectives of this systematic review and meta-analysis were to compare all-cause mortality, HD access primary patency, and circuit primary patency after endovascular maintenance procedures using PCB angioplasty vs PBA. METHODS MEDLINE, Embase, and Cochrane Databases were systematically searched to identify all the relevant studies on paclitaxel-coated devices for stenosis or thrombosis of HD access. A random effects model was applied to pool the effect measures. Dichotomous data were presented using an odds ratio (OR). Effect data were presented using pooled hazard ratio (HR) with 95% confidence interval (CI). RESULTS A total of 16 studies were included in this meta-analysis, 12 randomized controlled trials and 4 cohort studies involving 1086 patients who underwent endovascular treatment for HD access stenosis or occlusion. All-cause mortality rates at 6, 12, and 24 months after intervention were similar between the PCB and PBA groups (6 months: OR, 1.06 [95% CI, 0.38-2.96; P = .907; I2 = 19.2%]; 12 months: OR, 1.20 [95% CI, 0.66-2.16; P = .554; I2 = 0%]; 24 months: OR, 1.43 [95% CI, 0.83-2.45; P = .195; I2 = 0%]). There was a significant improvement of primary patency in the PCB group compared with the PBA group (HR, 0.47; 95% CI, 0.33-0.69; P < .001; I2 = 67.3%). This benefit was consistent with the analysis of randomized controlled trials, whereas cohort studies were excluded. Further subgroup analysis of target lesions demonstrated that primary patency was significantly higher in the PCB group than in the PBA group, not only for arteriovenous fistula (HR, 0.54; 95% CI, 0.30-0.98; P = .041; I2 = 76.8%) but also for central venous stenosis (HR, 0.39; 95% CI, 0.22-0.71; P = .002; I2 = 0%). The PCB group was associated with higher 6-month (OR, 0.40; 95% CI, 0.27-0.59; P < .001) and 24-month lesion primary patency (OR, 0.28; 95% CI, 0.11-0.72; P = .009) than PBA and was marginally associated with 12-month lesion primary patency (OR, 0.52; 95% CI, 0.26-1.03; P = .06). Circuit primary patency analysis showed a marginal trend toward better outcome in the PCB group (HR, 0.63; 95% CI, 0.40-1.00) but no statistical significance (P = .052). CONCLUSIONS This systematic review and meta-analysis demonstrated that PCB angioplasty is associated with significantly improved primary patency of arteriovenous fistula and central venous stenosis for HD access maintenance, with no evidence of increasing all-cause mortality based on short-term and midterm follow-up. Further large cohort study is needed to investigate long-term mortality.
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Affiliation(s)
- Xiyang Chen
- Department of Vascular Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yang Liu
- Department of Vascular Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Jiarong Wang
- Department of Vascular Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Jichun Zhao
- Department of Vascular Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Niten Singh
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Washington and Puget Sound VA Health Care System, Seattle
| | - Wayne W Zhang
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Washington and Puget Sound VA Health Care System, Seattle.
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Karmota AG. Paclitaxel coated-balloon (PCB) versus standard plain old balloon (POB) fistuloplasty for failing dialysis access. Ann R Coll Surg Engl 2020; 102:601-605. [PMID: 32538115 DOI: 10.1308/rcsann.2020.0121] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION This study aimed to evaluate the safety and efficacy of paclitaxel-coated balloon compared with conventional plain balloon for the treatment of failing native dialysis access. MATERIALS AND METHODS This prospective study included 60 patients presenting to the Kasr Alainy Hospitals and Aseer Central Hospital in the period from September 2015 to December 2017 with failing native vascular access. Dilatation with a plain balloon was done in 30 patients (group I) and with a paclitaxel-coated balloon in 30 patients (group II) with either stenosis or occlusion. The majority were outflow lesions, with 20 (66.7 %) patients in group I and 21 (70%) patients in group II. Mean balloon diameter was 7.1mm (± 1.5mm) compared with 6.5mm (± 1.2mm) and length 66mm (± 19.1mm) compared with 54.6mm (± 15.7mm), respectively. Safety endpoint was reported as 30 day's freedom from procedure-related major complications and mortality. Procedural technical success was defined as a residual diameter 30% or less for treated lesions. Target lesion primary patency, circuit primary patency and secondary patency were reported at 3, 6 and 12 months. RESULTS There were no 30-day procedure-related major complications or mortality in either group. Procedural technical success of 100% was achieved in both groups. Target lesion primary patency, circuit primary patency and secondary patency in group II were better than in group I, especially at 12 months (90% vs 66.7%, 83.3% vs 60% and 96.7% vs 93.3%, respectively). There was a statistically significant difference in target lesion primary patency (p = 0.029) in patients who were treated with paclitaxel-coated balloon angioplasties. CONCLUSION The paclitaxel-coated balloon proved to be safe and effective, and improved the patency of failing vascular access. Results are comparable with previous studies.
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Affiliation(s)
- A G Karmota
- Faculty of Medicine, Kasr Alainy - Cairo University Hospitals, Cairo, Egypt
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Liao MT, Lee CP, Lin TT, Jong CB, Chen TY, Lin L, Hsieh MY, Lin MS, Chie WC, Wu CC. A randomized controlled trial of drug-coated balloon angioplasty in venous anastomotic stenosis of dialysis arteriovenous grafts. J Vasc Surg 2020; 71:1994-2003. [DOI: 10.1016/j.jvs.2019.07.090] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 07/30/2019] [Indexed: 11/16/2022]
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Patel DV, Saad TF, Hentschel DM. Advances in Endovascular Salvage. Adv Chronic Kidney Dis 2020; 27:219-227. [PMID: 32891306 DOI: 10.1053/j.ackd.2020.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 05/04/2020] [Accepted: 05/11/2020] [Indexed: 11/11/2022]
Abstract
Endovascular salvage plays an important role in dialysis access care. Angioplasty using standard high- and ultrahigh-pressure balloon is the mainstay of therapy, while the use of cutting balloons and balloons designed to deliver pharmacologically active agents to the site of recurrent stenosis is demonstrating improved performance for specific targets that have to be further defined. Stents and stent grafts are additional tools for use at access segments predisposed for inward remodeling such as the cephalic arch or basilic swing point. The juxta-anastomotic segment has particular relevance in maturation of autogenous accesses as well as maintenance of access flow volume. Depending on the location of the access in the forearm or upper arm, and which artery is feeding into the access vein, any type of balloon angioplasty and stent or stent graft placement may be used to establish and maintain patency. Successful management of dialysis access options relies on preservation of venous real estate during the chronic kidney disease phase of kidney disease as well as on knowledgeable evaluation of arm veins and the access by physical examination, bed side ultrasound, and angiographic studies.
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Liao MT, Chen MK, Hsieh MY, Yeh NL, Chien KL, Lin CC, Wu CC, Chie WC. Drug-coated balloon versus conventional balloon angioplasty of hemodialysis arteriovenous fistula or graft: A systematic review and meta-analysis of randomized controlled trials. PLoS One 2020; 15:e0231463. [PMID: 32287283 PMCID: PMC7156061 DOI: 10.1371/journal.pone.0231463] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/24/2020] [Indexed: 12/22/2022] Open
Abstract
Background Restenosis remains a significant problem in endovascular therapy for hemodialysis vascular access. Drug-coated balloon (DCB) angioplasty decreases restenosis in peripheral and coronary artery diseases. The aim of this systematic review and meta-analysis is to assess the patency outcomes following DCB angioplasty, as compared to conventional balloon (CB) angioplasty for the stenosis of hemodialysis vascular access. Methods A comprehensive search in the MEDLINE, EMBASE, and CENTRAL databases was conducted in order to identify eligible randomized controlled trials evaluating DCB angioplasty for hemodialysis vascular access dysfunction. The primary endpoint was the 6-month target lesion primary patency and the secondary endpoints were 12-month target lesion primary patency and procedure-related complications. Risk ratios (RR) were pooled and relevant subgroups were analyzed separately. Results Eleven randomized controlled trials comprised of 487 patients treated with DCB angioplasty and 489 patients treated with CB angioplasty were included. There were no significant differences in the target lesion primary patency at 6 months [RR, 0.75; 95% confidence interval (CI), 0.56, 1.01; p = 0.06] and at 12 months (RR 0.89; 95% CI, 0.79, 1.00; p = 0.06). The absence of benefit for the DCB group remained, even in the arteriovenous fistula subgroup or the subgroup of studies excluding central vein stenosis. The risk of procedure-related complication did not differ between the two groups (RR 1.00; 95% CI 0.98, 1.02; p = 0.95). Conclusion DCB angioplasty did not demonstrate significant patency benefit for the treatment of hemodialysis vascular access dysfunction. Wide variations in patency outcomes across studies were noted. Further studies focusing on specific types of access or lesions are warranted to clarify the value of DCB for hemodialysis vascular access. (PROSPERO Number CRD42019119938)
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Affiliation(s)
- Min-Tsun Liao
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan
| | - Meng-Kan Chen
- Department of Family Medicine, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan
| | - Mu-Yang Hsieh
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan
- College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Nai-Lun Yeh
- Department of Family Medicine, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan
| | - Kuo-Liong Chien
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Chih-Ching Lin
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Chih-Cheng Wu
- College of Medicine, National Taiwan University, Taipei, Taiwan
- Institute of Biomedical Engineering, National Tsing-Hua University, Hsinchu, Taiwan
- Cardiovascular Center, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan
- Institute of Cellular and System Medicine, National Health Research Institute, Zhunan, Taiwan
- * E-mail: (CCW); (WCC)
| | - Wei-Chu Chie
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan
- * E-mail: (CCW); (WCC)
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Yazar O, Provoost A, Broughton A, Ghijselings L, Leclef Y, Van Calster K, Reginster F, Fourneau I. Paclitaxel drug-coated balloon angioplasty for the treatment of failing arteriovenous fistulas: a single-center experience. Acta Chir Belg 2020; 120:85-91. [PMID: 30633638 DOI: 10.1080/00015458.2018.1561796] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objectives: To report our experience of angioplasty with Lutonix (Bard Peripheral Vascular, Inc., Tempe, AZ) drug-coated balloon (DCB) for the treatment of failing arteriovenous fistulas (AVF).Materials and methods: Retrospective, single-center analysis consisting of 14 patients treated with Lutonix paclitaxel DCBs in the period from July 2015 through April 2017. We analyzed technical success, clinical success, primary patency of the target lesion, primary patency of the dialysis circuit, and the rate of complications. Regular follow-up of AVF patency was realized by clinical examination and duplex ultrasonography. The Kaplan-Meier survival method was applied to determine the cumulative primary patency of the target lesion and the dialysis circuit.Results: Technical success was 100% and clinical success 92.9%. There were no major or minor complications. Cumulative target lesion primary patency after DCB was 69.2% at 6 months and 31.6% at 12 months. Cumulative vascular circuit primary patency was 61.5% at 6 months and 31.6% at 12 months.Conclusion: Compared to results reported in literature with plain old balloon angioplasty (POBA), Lutonix paclitaxel DCB angioplasty proved a short-term patency benefit in treatment of dialysis AVF stenosis.
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Affiliation(s)
- O. Yazar
- Department of Surgery, Europe Hospitals Brussels, Brussels, Belgium
| | - A. Provoost
- Department of Surgery, Europe Hospitals Brussels, Brussels, Belgium
| | - A. Broughton
- Department of Nephrology, Europe Hospitals Brussels, Brussels, Belgium
| | - L. Ghijselings
- Department of Radiology, Europe Hospitals Brussels, Brussels, Belgium
| | - Y. Leclef
- Department of Surgery, Europe Hospitals Brussels, Brussels, Belgium
| | - K. Van Calster
- Department of Surgery, Europe Hospitals Brussels, Brussels, Belgium
| | - F. Reginster
- Department of Nephrology, Europe Hospitals Brussels, Brussels, Belgium
| | - I. Fourneau
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
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Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, Allon M, Asif A, Astor BC, Glickman MH, Graham J, Moist LM, Rajan DK, Roberts C, Vachharajani TJ, Valentini RP. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis 2020; 75:S1-S164. [PMID: 32778223 DOI: 10.1053/j.ajkd.2019.12.001] [Citation(s) in RCA: 1001] [Impact Index Per Article: 250.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 12/09/2019] [Indexed: 02/07/2023]
Abstract
The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.
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Chong TT, Yap HY, Tan CS, Lee QS, Chan SL, Wee IJY, Tang TY. Use of Paclitaxel Coated Drug Eluting Technology to Improve Central Vein Patency for Haemodialysis Access Circuits: Any Benefit? Vasc Specialist Int 2020; 36:21-27. [PMID: 32292765 PMCID: PMC7119145 DOI: 10.5758/vsi.2020.36.1.21] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 12/08/2019] [Accepted: 03/04/2020] [Indexed: 11/24/2022] Open
Abstract
Purpose Central venous stenosis is a recurring problem affecting dialysis access patency. Increasing evidence suggests that the use of drug-coated balloons (DCBs) improves target lesion primary patency (TLPP) in dialysis access. However, few studies have investigated the use of DCBs specifically in central venous stenosis. Thus, this study presents our initial experience with DCBs in the central vein of a dialysis access circuit. Materials and Methods This is a retrospective cohort study of all hemodialysis patients who underwent central vein angioplasty with DCB between February 2017 and March 2018 at Singapore General Hospital. We compared the primary patency post DCB angioplasty to the primary patency of the patient’s previous plain old balloon angioplasty (POBA). Results We observed a 100% anatomic and procedural success rate with no complications. The median follow-up period was 151 days (interquartile range, 85.5-234 days) and no patients were lost to follow-up. The 30- and 90-day TLPPs after DCB were 93.3% and 75.7%, respectively. The mean primary patency in our study group post-DCB during the follow-up period was 164 days (vs. 140 days in the POBA group). However, no statistically significant difference was detected. Conclusion DCB showed a similar TLPP to that for POBA in treating central venous stenosis with a trend toward a longer re-intervention-free period for DCB. However, there were numerous confounding factors and a well-designed randomized controlled trial is warranted to assess the true utility of DCB in treating central venous stenosis.
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Affiliation(s)
- Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Hao Yun Yap
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Chieh Suai Tan
- Department of Interventional Nephrology, Singapore General Hospital, Singapore
| | - Qingwei Shaun Lee
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Sze Ling Chan
- Health Services Research Center, SingHealth, Singapore
| | - Ian Jun Yan Wee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tjun Yip Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore
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43
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Rokoszak V, Syed MH, Salata K, Greco E, de Mestral C, Hussain MA, Aljabri B, Verma S, Al-Omran M. A systematic review and meta-analysis of plain versus drug-eluting balloon angioplasty in the treatment of juxta-anastomotic hemodialysis arteriovenous fistula stenosis. J Vasc Surg 2020; 71:1046-1054.e1. [DOI: 10.1016/j.jvs.2019.07.075] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 07/15/2019] [Indexed: 10/25/2022]
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44
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Cao Z, Li J, Zhang T, Zhao K, Zhao J, Yang Y, Jiang C, Zhu R, Li Z, Wu W. Comparative Effectiveness of Drug-Coated Balloon vs Balloon Angioplasty for the Treatment of Arteriovenous Fistula Stenosis: A Meta-analysis. J Endovasc Ther 2020; 27:266-275. [PMID: 32043432 DOI: 10.1177/1526602820902757] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To compare the effectiveness and safety outcomes of drug-coated balloon angioplasty (DCBA) vs conventional balloon angioplasty (BA) for arteriovenous fistula (AVF) stenosis. Materials and Methods: A systematic review was conducted of PubMed and Embase databases from 1966 to May 2019 to identify English-language articles evaluating DCBA vs BA for the treatment of AVF stenosis. Data extracted from each study were synthesized to evaluate target lesion revascularization (TLR), technical success, and mortality for the 2 approaches. Meta-analyses were performed on these outcomes using random effects models to estimate the odds ratios (ORs) and 95% confidence intervals (CIs). Subgroup and sensitivity analyses were performed. Results: Twelve studies [6 randomized controlled trials (RCTs) and 6 cohort studies] comprising 979 patients were included in this meta-analysis. The pooled results showed that AVFs treated with DCBA had significantly fewer TLRs at 6 months (OR 0.31, 95% CI 0.14 to 0.69, p=0.004) and 12 months (OR 0.45, 95% CI 0.21 to 0.97, p=0.04) than BA. The 2 approaches had similar technical success rates (OR 0.22, 95% CI 0.03 to 1.43, p=0.11). Additionally, the pooled OR of 12-month mortality was 0.71 (95% CI 0.20 to 2.51, p=0.60), indicating no significant difference between DCBA and BA. Subgroup analysis based on study design showed the superiority of DCBA to BA in cohort studies but not RCTs, which had high heterogeneity. Significant publication bias was found in the cohort studies. Conclusion: In de novo or recurrent AVF stenosis, DCBA appears to be an effective procedure associated with lower 6- and 12-month TLR compared with BA. However, larger and randomized controlled studies are warranted to draw definitive conclusions.
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Affiliation(s)
- Zhanjiang Cao
- Department of Vascular Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jiazheng Li
- Department of Vascular Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Tong Zhang
- Department of Vascular Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Keqiang Zhao
- Department of Vascular Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Junlai Zhao
- Department of Vascular Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yu Yang
- Department of Vascular Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Chao Jiang
- Department of Vascular Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Rongrong Zhu
- Department of Vascular Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Zipeng Li
- Department of Vascular Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Weiwei Wu
- Department of Vascular Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
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45
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The Lutonix AV Randomized Trial of Paclitaxel-Coated Balloons in Arteriovenous Fistula Stenosis: 2-Year Results and Subgroup Analysis. J Vasc Interv Radiol 2020; 31:1-14.e5. [DOI: 10.1016/j.jvir.2019.08.035] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/12/2019] [Accepted: 08/20/2019] [Indexed: 11/21/2022] Open
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46
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Dinh K, Thomas SD, Cho T, Swinnen J, Crowe P, Varcoe RL. Use of Paclitaxel Eluting Stents in Arteriovenous Fistulas: A Pilot Study. Vasc Specialist Int 2019; 35:225-231. [PMID: 31915667 PMCID: PMC6941774 DOI: 10.5758/vsi.2019.35.4.225] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/17/2019] [Accepted: 11/21/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose We report short-term patency outcomes of a proof of concept study conducted to determine the efficacy of drug-eluting stent (DES) for the treatment of arteriovenous fistula (AVF) stenosis in hemodialysis patients. Materials and Methods This is a single-center, retrospective observational study involving 10 patients with AVF dysfunction treated with DESs between January 2017 and December 2017. The primary outcome was AVF patency confirmed by sonographic and clinical assessment at 1 month and 6 to 9 months after treatment. Results A total of 12 DESs were deployed in 10 patients with dysfunctional AVF (radiocephalic: 7, brachiocephalic: 3). During the early follow up (mean: 28.6 days), primary access circuit and DES patency was 100%, with an average volume flow rate of 886.4 mL/min. Nine patients were available for short-term follow up (mean: 202.4 days; 1 unrelated death), with a mean volume flow rate of 1,048.9 mL/min. The primary DES patency was 7/9 (77.8%), and 3 patients required angioplasty at other parts of the circuit (primary access circuit patency: 4/9 [44.4%]). The assisted primary access circuit patency was 77.8%. In 2 patients, the ultrasound revealed that the DESs were thrombosed without any antecedent stenosis; they were salvaged with angioplasty. Both patients previously underwent 2 DESs implanted and recently stopped dual antiplatelet therapy. B-mode sonographic assessment at all timepoints showed minimal intimal ingrowth on the stent struts. Conclusion This study demonstrates acceptable short-term patency for DESs in the treatment of AVF stenosis. Dual antiplatelet therapy is probably mandatory in the short term.
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Affiliation(s)
- Krystal Dinh
- Department of Surgery, Prince of Wales Hospital, Australia.,Department of Vascular Surgery, Westmead Hospital, Australia
| | - Shannon D Thomas
- Department of Surgery, Prince of Wales Hospital, Australia.,Faculty of Medicine, University of New South Wales, Australia.,The Vascular Institute, Prince of Wales Hospital, Sydney, Australia
| | - Tae Cho
- Department of Vascular Surgery, Westmead Hospital, Australia
| | - John Swinnen
- Department of Vascular Surgery, Westmead Hospital, Australia
| | - Phillip Crowe
- Faculty of Medicine, University of New South Wales, Australia
| | - Ramon L Varcoe
- Department of Surgery, Prince of Wales Hospital, Australia.,Faculty of Medicine, University of New South Wales, Australia.,The Vascular Institute, Prince of Wales Hospital, Sydney, Australia
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Efficacy of Paclitaxel Balloon for Hemodialysis Stenosis Fistulae After One Year Compared to High-Pressure Balloons: A Controlled, Multicenter, Randomized Trial. Cardiovasc Intervent Radiol 2019; 43:382-390. [DOI: 10.1007/s00270-019-02372-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 10/31/2019] [Indexed: 12/31/2022]
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48
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Yan Wee IJ, Yap HY, Hsien Ts'ung LT, Lee Qingwei S, Tan CS, Tang TY, Chong TT. A systematic review and meta-analysis of drug-coated balloon versus conventional balloon angioplasty for dialysis access stenosis. J Vasc Surg 2019; 70:970-979.e3. [DOI: 10.1016/j.jvs.2019.01.082] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/19/2019] [Indexed: 11/28/2022]
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49
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Dinh K, Limmer AM, Paravastu SCV, Thomas SD, Bennett MH, Holden A, Varcoe RL. Mortality After Paclitaxel-Coated Device Use in Dialysis Access: A Systematic Review and Meta-Analysis. J Endovasc Ther 2019; 26:600-612. [DOI: 10.1177/1526602819872154] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Purpose: To report the risk of all-cause mortality in patients who underwent dialysis access treatment using paclitaxel-coated devices compared with percutaneous transluminal angioplasty (PTA) with an uncoated balloon. Materials and Methods: A systematic review and meta-analysis of randomized controlled trials were performed to investigate the mortality outcomes associated with paclitaxel-coated devices in the treatment of patients with a failing dialysis access (last search date February 28, 2019). The primary endpoint was all-cause mortality. This analysis included 8 studies comparing paclitaxel-coated balloon (PCB) angioplasty (n=327) and PTA (n=331) in the treatment of failing dialysis access. None investigated paclitaxel-coated stents. Mortality data were pooled using a random effects model. Statistical heterogeneity was evaluated with a chi-square test and the I2 statistic. Summary statistics are expressed as relative risk ratios (RR) with a 95% confidence interval (CI). Results: At the pooled mean follow-up of 13.5 months (median 12, range 6–24) all-cause mortality was similar in the PCB group (13.8%) compared with PTA (11.2%; RR 1.26, 95% CI 0.85 to 1.89, p=0.25; I2=0%). Subgroup analysis, stratified according to length of follow-up, confirmed that there were no statistically significant differences in mortality at short- and midterm follow-up [6-month (8 studies): 5.2% vs 4.8%, RR 1.24, 95% CI 0.62 to 2.47, p=0.55; 12-month (6 studies): 6.3% vs 6.0%, RR 1.06, 95% CI 0.43 to 2.63, p=0.90; and 24-month (3 studies): 19.0% vs 13.5%, RR 1.38, 95% CI 0.90 to 2.12, p=0.14). Conclusion: The analysis found no difference in short- to midterm mortality among patients treated with a drug-coated balloon compared with PTA. With proven benefit and no evidence of harm, the authors recommend ongoing use of PCB for the failing dialysis access.
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Affiliation(s)
- Krystal Dinh
- Department of Vascular Surgery, Westmead Hospital, Westmead, New South Wales, Australia
| | - Alexandra M. Limmer
- Department of Surgery, Westmead Hospital, Westmead, New South Wales, Australia
| | - Sharath C. V. Paravastu
- Department of Vascular Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire, UK
| | - Shannon D. Thomas
- Department of Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- The Vascular Institute, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Michael H. Bennett
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Department of Anaesthesia, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Andrew Holden
- Department of Interventional Radiology, Auckland Hospital, Auckland, New Zealand
| | - Ramon L. Varcoe
- Department of Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- The Vascular Institute, Prince of Wales Hospital, Sydney, New South Wales, Australia
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A randomized feasibility study of the effect of ascorbic acid on post-angioplasty restenosis of hemodialysis vascular access (NCT03524846). Sci Rep 2019; 9:11095. [PMID: 31366980 PMCID: PMC6668477 DOI: 10.1038/s41598-019-47583-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 07/16/2019] [Indexed: 12/16/2022] Open
Abstract
Restenosis remains a significant problem after angioplasty of hemodialysis vascular access. Both experimental and clinical studies have shown a protective effect of antioxidants against post-angioplasty restenosis. A prospective, randomized, feasibility study was conducted to investigate the effect of ascorbic acid to prevent restenosis. Ninety-three hemodialysis patients were randomized into three groups after angioplasty: placebo (n = 31), 300 mg ascorbic acid (n = 31), and 600 mg ascorbic acid (n = 31), treated intravenously 3 times per week for 3 months. Eighty-nine completed the clinical follow-up, and 81 had angiographic follow-up. In the angiographic follow-up, the mean (stand deviation) late loss of luminal diameter for the placebo, 300 mg, and 600 mg groups were 3.15 (1.68) mm, 2.52 (1.70) mm (P = 0.39 vs. placebo group), and 1.59 (1.67) mm (P = 0.006, vs. placebo group), with corresponding angiographic binary restenosis of 79%, 67% (P = 0.38 vs. placebo group), and 54% (P = 0.08 vs. placebo group). The post-interventional primary patency rates at 3 months were 47%, 55% (P = 0.59 vs. placebo group), and 70% (P = 0.18 vs. placebo group) for placebo, 300 mg, and 600 mg groups. Our results demonstrated that intravenous 600 mg ascorbic acid was a feasible therapy and might attenuate restenosis after angioplasty; however, its effect on post-interventional primary patency was modest.
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