1
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Harduin LDO, Barroso TA, Guerra JB, Filippo MG, de Almeida LC, Vieira BR, Mello RS, Galhardo AM, Strogoff-de-Matos JP. Safety and Performance of a Cell-Impermeable Endoprosthesis for Hemodialysis Vascular Access Outflow Stenosis: A Brazilian Multicenter Retrospective Study. Cardiovasc Intervent Radiol 2024:10.1007/s00270-024-03790-1. [PMID: 38955816 DOI: 10.1007/s00270-024-03790-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 06/10/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE To evaluate the safety and performance of Wrapsody™, a cell-impermeable endoprosthesis (CIE), for treating hemodialysis vascular access outflow stenosis. MATERIALS AND METHODS Investigators retrospectively analyzed 113 hemodialysis patients treated with a CIE (11/2021-12/2022) across four centers in Brazil. De novo or restenotic lesions were treated. The primary efficacy outcome measure was target lesion primary patency (TLPP) at 1, 3, 6, and 12 months; the primary safety outcome measure was the absence of serious local or systemic adverse events within the first 30 days post-procedure. Secondary outcome measures included technical and procedural success, access circuit primary patency (ACPP), and secondary patency at 1, 3, 6, and 12 months post-procedure. RESULTS Thirty-nine patients (34.5%) had thrombosed access at the initial presentation, and 38 patients (33.6%) presented with recurrent stenosis. TLPP rates at 1, 3, 6, and 12 months were 100%, 96.4%, 86.4%, and 69.7%, respectively. ACPP rates were 100% at 1 month, 89.2% at 3 months, 70.9% at 6 months, and 56.0% at 12 months. The target lesion secondary patency rates at 1, 3, 6, and 12 months were 100%, 97.3%, 93.6%, and 91.7%, respectively. In the adjusted multivariate Cox regression analysis, male sex and endoprosthesis with diameters of 10, 12, 14, and 16 mm were associated with improved primary patency rates. No localized or systemic serious adverse event was observed through the first 30 days post-procedure. CONCLUSION The CIE evaluated in this study is safe and effective for treating peripheral and central outflow stenoses in hemodialysis vascular access. LEVEL OF EVIDENCE Level 2b, cohort study.
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Affiliation(s)
| | | | - Julia Bandeira Guerra
- Image Department, Hospital Niterói Dor and Centro Clínico LIVCARE, Niterói, Rio de Janeiro, Brazil
| | - Márcio Gomes Filippo
- Vascular Surgery Service, Hospital Universitário Clementino Fraga Filho (HUCFF), Universidade Federal do Estado do Rio de Janeiro (UFRJ), Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Brunno Ribeiro Vieira
- Instituto Nacional de Traumatologia e Ortopedia, Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Jorge Paulo Strogoff-de-Matos
- Divisão de Nefrologia, Departamento de Medicina, Faculdade de Medicina, Universidade Federal Fluminense, Niterói, Rio de Janeiro, Brazil
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2
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Drouven JW, de Bruin C, van Roon, PhD AM, Ozyilmaz A, Oldenziel J, Bokkers RPH, Zeebregts CJ. Use of Covered Stents in Cannulation Sites as a Last Option to Salvage Failing Vascular Access. J Endovasc Ther 2024; 31:98-103. [PMID: 35972139 PMCID: PMC10773153 DOI: 10.1177/15266028221116745] [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]
Abstract
PURPOSE Controversy exists regarding the treatment of recurrent stenosis in vascular access at cannulation sites with a covered stent as repeated cannulation may damage the stent. The purpose of this study was to review covered stent placement at cannulation sites to salvage failing vascular access. MATERIALS AND METHODS A total of 11 patients were included for the purpose of this study. Eight patients (72.7%) received a covered stent due to recurrent stenosis, 2 (18.2%) due to an acute occlusion, and in 1 case (9.1%), the covered stent was used to repair a damaged polytetrafluoroethylene arteriovenous graft (PTFE AVG). RESULTS Primary patency after stent placement was 40.9% at 6 months, primary-assisted patency was 79.5% at 12 months, and secondary patency was 80% at 24 months. No significant problems were observed during the dialysis sessions after stent placement. The intervention rate per patient-year was not significantly different before or after covered stent placement, at 3.8 (IQR=9.5) interventions per year versus 2.5 (IQR=3.0) interventions per year (p=0.280). CONCLUSION In conclusion, treating failing vascular access with problems at cannulation sites with covered stents can be considered. CLINICAL IMPACT Treating vascular access stenosis at cannulation sites with covered stents can successfully prolong vascular access life.
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Affiliation(s)
- Johannes W. Drouven
- Departments of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Cor de Bruin
- Departments of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Arie M. van Roon, PhD
- Internal Medicine, Division of Vascular Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Akin Ozyilmaz
- Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Job Oldenziel
- Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Reinoud P. H. Bokkers
- Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Clark J. Zeebregts
- Departments of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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3
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Tan RY, Tng ARK, Tan CW, Pang SC, Zhuang KD, Tay KH, Tang TY, Chong TT, Tan CS. Sirolimus-coated balloon angioplasty in maintaining the patency of thrombosed arteriovenous graft: 1-year results of a prospective study. J Vasc Access 2024; 25:274-279. [PMID: 35686321 PMCID: PMC10845821 DOI: 10.1177/11297298221104310] [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: 03/30/2022] [Accepted: 05/11/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND A prospective, pilot study was designed to test the feasibility of using sirolimus-coated balloon (SCB) to treat graft vein junction of thrombosed arteriovenous graft (AVG) following successful pharmacomechanical thrombectomy. The present report provides the 1-year results of this study. METHODS This is a 1-year follow-up of a single, prospective, single-arm study that was conducted from 2018 to 2019 in 20 patients who presented to a tertiary institution with thrombosed AVG. The recruited patients received SCB angioplasty at the graft-vein junction following successful endovascular thrombectomy of a thrombosed AVG. One year after recruitment, there were three deaths, one AVG revision, and one AVG explantation among the participants recruited. The outcomes of 15 subjects at 1-year following the index procedure obtained from electronic medical records were re-examined. RESULTS The 1-year access circuit primary patency rate was 40%, while assisted primary and secondary patency rates were 46.7% and 73.3%, respectively. A total of 16 interventions (4 angioplasties, 12 thrombectomies) were performed in 9 patients over the 12 months. Four AVGs were abandoned. The median number of interventions per patient was 1 (0-3) per year. Using Kaplan-Meier analysis, the mean estimated post-intervention access circuit primary patency was 230 (95% CI: 162-300) days, while access circuit assisted primary patency was 253 (95% CI: 187-320) days, and access circuit secondary patency was 292 (95% CI: 230-356) days. Sub-group analysis did not show a significant difference in the mean estimated primary patency between AVG with de novo and recurrent stenosis (245 days, 95% CI: 151-339 vs 210 days, 95% CI: 113-307; p = 0.29). CONCLUSIONS SCB may help sustain the patency of thrombosed AVG following successful thrombectomy.
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Affiliation(s)
- Ru Yu Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
- Duke-NUS Graduate Medical School, Singapore
| | - Alvin Ren Kwang Tng
- Department of Renal Medicine, Singapore General Hospital, Singapore
- Duke-NUS Graduate Medical School, Singapore
| | - Chee Wooi Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
- Duke-NUS Graduate Medical School, Singapore
| | - Suh Chien Pang
- Department of Renal Medicine, Singapore General Hospital, Singapore
- Duke-NUS Graduate Medical School, Singapore
| | - Kun Da Zhuang
- Duke-NUS Graduate Medical School, Singapore
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - Kiang Hiong Tay
- Duke-NUS Graduate Medical School, Singapore
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - Tjun Yip Tang
- Duke-NUS Graduate Medical School, Singapore
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Tze Tec Chong
- Duke-NUS Graduate Medical School, Singapore
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Chieh Suai Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
- Duke-NUS Graduate Medical School, Singapore
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4
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Higgins MCSS, Diamond M, Mauro DM, Kapoor BS, Steigner ML, Fidelman N, Aghayev A, Chamarthy MRK, Dedier J, Dillavou ED, Felder M, Lew SQ, Lockhart ME, Siracuse JJ, Dill KE, Hohenwalter EJ. ACR Appropriateness Criteria® Dialysis Fistula Malfunction. J Am Coll Radiol 2023; 20:S382-S412. [PMID: 38040461 DOI: 10.1016/j.jacr.2023.08.016] [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: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
The creation and maintenance of a dialysis access is vital for the reduction of morbidity, mortality, and cost of treatment for end stage renal disease patients. One's longevity on dialysis is directly dependent upon the quality of dialysis. This quality hinges on the integrity and reliability of the access to the patient's vascular system. All methods of dialysis access will eventually result in dialysis dysfunction and failure. Arteriovenous access dysfunction includes 3 distinct classes of events, namely thrombotic flow-related complications or dysfunction, nonthrombotic flow-related complications or dysfunction, and infectious complications. The restoration of any form of arteriovenous access dysfunction may be supported by diagnostic imaging, clinical consultation, percutaneous interventional procedures, surgical management, or a combination of these methods. This document provides a rigorous evaluation of how variants of each form of dysfunction may be appraised and approached systematically. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Matthew Diamond
- Research Author, Boston Medical Center, Boston, Massachusetts
| | - David M Mauro
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | | | | | - Nicholas Fidelman
- Panel Vice-Chair, University of California San Francisco, San Francisco, California
| | - Ayaz Aghayev
- Brigham & Women's Hospital, Boston, Massachusetts
| | - Murthy R K Chamarthy
- Vascular Institute of North Texas, Dallas, Texas; Commission on Nuclear Medicine and Molecular Imaging
| | - Julien Dedier
- Boston Medical Center, Boston, Massachusetts, Primary care physician
| | - Ellen D Dillavou
- WakeMed Hospital System, Raleigh, North Carolina; Society for Vascular Surgery
| | - Mila Felder
- Advocate Christ Medical Center, Oak Lawn, Illinois; American College of Emergency Physicians
| | - Susie Q Lew
- George Washington University, Washington, District of Columbia; American Society of Nephrology
| | | | - Jeffrey J Siracuse
- Boston University School of Medicine, Boston, Massachusetts; Society for Vascular Surgery
| | - Karin E Dill
- Specialty Chair, Emory University Hospital, Atlanta, Georgia
| | - Eric J Hohenwalter
- Specialty Chair, Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin
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5
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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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6
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Haskal ZJ, Dolmatch BL. Hemodialysis Access Stent Graft Trials: Past, Present, and Future. Cardiovasc Intervent Radiol 2023; 46:1154-1161. [PMID: 36941431 DOI: 10.1007/s00270-023-03389-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/07/2023] [Indexed: 03/23/2023]
Affiliation(s)
- Ziv J Haskal
- School of Medicine, University of Virginia, Charlottesville, USA.
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7
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Hsieh MY, Lin PS, Liao MT, Lin L, Chen TY, Boon JC, Yang TF, Wu CC. A Randomised Trial Comparing Drug Coated Balloons and Conventional Balloons for the Treatment of Stent Graft Stenosis in Dialysis Vascular Access. Eur J Vasc Endovasc Surg 2023; 66:253-260. [PMID: 37209996 DOI: 10.1016/j.ejvs.2023.05.028] [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: 11/07/2022] [Revised: 04/28/2023] [Accepted: 05/13/2023] [Indexed: 05/22/2023]
Abstract
OBJECTIVE Previous studies on arteriovenous fistulas have demonstrated the potential benefit of drug coated balloons (DCBs) in maintaining the patency of dialysis access. However, stenoses involving stent grafts were excluded from these studies. Therefore, the aim was to evaluate the effectiveness of DCBs in treating stent graft stenosis. METHODS This was a prospective, single blinded, randomised controlled study. From March 2017 to April 2021, 40 patients with dysfunctional vascular access owing to stent graft stenosis were randomised to treatment with a DCB or conventional balloon. Clinical follow up was scheduled at one, three, and six months, and angiographic follow up was performed six months after the intervention. The primary outcome was angiographic late luminal loss at six months, and secondary outcomes included target lesion and access circuit primary patency at six months. RESULTS Thirty-six participants completed follow up angiography. The DCB group had a superior mean late luminal loss at six months compared with the control group (1.82 mm ± 1.83 mm vs. 3.63 mm ± 1.08 mm, respectively, p = .001). All 40 patients completed clinical follow up. The DCB group had a superior six month target lesion primary patency compared with the control group [hazard ratio (HR) 0.23, 95% confidence interval (CI) 0.07 - 0.71; p = .005). Additionally, the DCB group had a numerically higher six month access circuit primary patency rate than the control group, although the difference was not statistically significant (HR 0.54, 95% CI 0.26 - 1.11, p = .095). CONCLUSION Conventional balloon angioplasty is not durable in stent graft stenosis treatment. Treatment with DCBs provides less angiographic late luminal loss and potentially superior primary patency of the target lesion than treatment with conventional balloons. [ClinicalTrials ID: NCT03360279.].
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Affiliation(s)
- Mu-Yang Hsieh
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu, Taiwan; Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan; College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Pei-Shan Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Min-Tsun Liao
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan; College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Lin Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Tsung-Yan Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Jong-Chien Boon
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Ten-Fang Yang
- Department of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu, Taiwan; Taipei Medical University and Hospital, Taipei, Taiwan
| | - Chih-Cheng Wu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan; College of Medicine, National Taiwan University, Taipei, Taiwan; Institute of Biomedical Engineering, National Tsing-Hua University, Hsinchu, Taiwan; Institute of Cellular and System Medicine, National Health Research Institutes, Zhunan, Taiwan; Centre of Quality Management, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan.
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8
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Cahalane AM, Irani Z, Cui J. Beyond the Veins: Uncovering the History and Advancements of Vascular Access. KIDNEY360 2023; 4:1150-1154. [PMID: 37322593 PMCID: PMC10476679 DOI: 10.34067/kid.0000000000000180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 05/04/2023] [Indexed: 06/17/2023]
Affiliation(s)
- Alexis M. Cahalane
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Zubin Irani
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Jie Cui
- Division of Interventional Radiology, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
- Nephrology Division, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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9
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Dolmatch B, Cabrera T, Pergola P, Balamuthusamy S, Makris A, Cooper R, Moore E, Licht J, Macaulay E, Maleux G, Pfammatter T, Settlage R, Cristea E, Lansky A. Prospective, randomized, multicenter clinical study comparing a self-expanding covered stent to percutaneous transluminal angioplasty for treatment of upper extremity hemodialysis arteriovenous fistula stenosis. Kidney Int 2023; 104:189-200. [PMID: 36990214 DOI: 10.1016/j.kint.2023.03.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 03/02/2023] [Accepted: 03/09/2023] [Indexed: 03/29/2023]
Abstract
Use of a covered stent after percutaneous transluminal angioplasty (PTA) was compared to PTA alone for treatment of upper extremity hemodialysis patients with arteriovenous fistula (AVF) stenoses. Patients with AVF stenosis of 50% or more and evidence of AVF dysfunction underwent treatment with PTA followed by randomization of 142 patients to include a covered stent or 138 patients with PTA alone. Primary outcomes were 30-day safety, powered for noninferiority, and six-month target lesion primary patency (TLPP), powered to test whether TLPP after covered-stent placement was superior to PTA alone. Twelve-month TLPP and six-month access circuit primary patency (ACPP) were also hypothesis tested while additional clinical outcomes were observed through two years. Safety was significantly non-inferior while six- and 12-month TLPP were each superior for the covered stent group compared to PTA alone (six months: 78.7% versus 55.8%; 12 months: 47.9% versus 21.2%, respectively). ACPP was not statistically different between groups at six-months. Observed differences at 24 months favored the covered-stent group: 28.4% better TLPP, fewer target-lesion reinterventions (1.6 ± 1.6 versus 2.8 ± 2.0), and a longer mean time between target-lesion reinterventions (380.4 ± 249.5 versus 217.6 ± 158.4 days). Thus, our multicenter, prospective, randomized study of a covered stent used to treat AVF stenosis demonstrated noninferior safety with better TLPP and fewer target-lesion reinterventions than PTA alone through 24 months.
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Affiliation(s)
- Bart Dolmatch
- Interventional Radiology, Palo Alto Medical Foundation, Mountain View, California, USA; Interventional Radiology, El Camino Hospital, Mountain View, California, USA.
| | | | | | - Saravanan Balamuthusamy
- Tarrant Nephrology Associates, Fort Worth, Texas, USA; Department of Medicine and Nephrology, Texas Christian University School of Medicine, Fort Worth, Texas, USA
| | | | - Randy Cooper
- Southwest Kidney Institute Vascular Center, Tempe, Arizona, USA
| | - Erin Moore
- Cardiothoracic & Vascular Surgical Associates, Jacksonville, Florida, USA; Department of Vascular Surgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Jonah Licht
- Providence Interventional Associates, Providence, Rhode Island, USA; Division of Nephrology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Ewan Macaulay
- Department of Vascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Geert Maleux
- Department of Vascular and Interventional Radiology, University Hospitals KU Leuven, Leuven, Belgium
| | - Thomas Pfammatter
- Department of Diagnostic and Interventional Radiology, University of Zürich Hospital, Zürich, Switzerland
| | - Richard Settlage
- Medical Affairs Department, Becton, Dickinson and Company, Colorado Springs, Colorado, USA
| | - Ecaterina Cristea
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Alexandra Lansky
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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10
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Mendes D, Almeida P, Pinelo A, Castro J, Norton-de-Matos A. Antecubital perforating vein stent-grafting for radiocephalic arteriovenous fistula recovery: A case report. Semin Dial 2023; 36:348-351. [PMID: 37245998 DOI: 10.1111/sdi.13158] [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: 12/08/2022] [Revised: 04/23/2023] [Accepted: 05/16/2023] [Indexed: 05/30/2023]
Abstract
Stent-grafts have been increasingly used in hemodialysis arteriovenous accesses, particularly in recurrent stenosis or in cases of vein rupture after percutaneous transluminal angioplasty (PTA). Although they limit neointimal hyperplasia, stenosis development at stent edges remains a concern. Despite their advantages, they are seldom used on the forearm veins due to fracture risk associated with elbow motion and the potential to limit cannulation sites. This report presents a novel application of stent-grafts in salvaging a radio-cephalic arteriovenous fistula in an 84-year-old male to treat a single outflow path at the elbow through a stenosed antecubital perforating vein, after failed PTA. The vascular access remained patent 18 months after the procedure, with no need for additional treatments at this target lesion, even though a PTA was required for juxta-anastomotic stenosis. This report highlights a possible further use of covered stents in arteriovenous vascular accesses.
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Affiliation(s)
- Daniel Mendes
- Vascular Access Center (Grupo Estudos Vasculares - GEV), Porto, Portugal
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal
| | - Paulo Almeida
- Vascular Access Center (Grupo Estudos Vasculares - GEV), Porto, Portugal
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Andreia Pinelo
- Vascular Access Center (Grupo Estudos Vasculares - GEV), Porto, Portugal
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - João Castro
- Vascular Access Center (Grupo Estudos Vasculares - GEV), Porto, Portugal
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário de Santo António, Porto, Portugal
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11
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Aslan A, Stevens C, Aldine AS, Mamilly A, De Alba L, Arevalo O, Ahuja C, Cuellar HH. The reproducibility of interventional radiology randomized controlled trials and external validation of a classification system. Diagn Interv Radiol 2023; 29:529-534. [PMID: 37070845 PMCID: PMC10679611 DOI: 10.4274/dir.2023.222052] [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: 01/19/2023] [Accepted: 02/24/2023] [Indexed: 04/19/2023]
Abstract
PURPOSE The fragility index (FI) measures the robustness of randomized controlled trials (RCTs). It complements the P value by taking into account the number of outcome events. In this study, the authors measured the FI for major interventional radiology RCTs. METHODS Interventional radiology RCTs published between January 2010 and December 2022 relating to trans-jugular intrahepatic portosystemic shunt, trans-arterial chemoembolization, needle biopsy, angiography, angioplasty, thrombolysis, and nephrostomy tube insertion were analyzed to measure the FI and robustness of the studies. RESULTS A total of 34 RCTs were included. The median FI of those studies was 4.5 (range 1-68). Seven trials (20.6%) had a number of patients lost to follow-up that was higher than their FI, and 15 (44.1%) had a FI of 1-3. CONCLUSION The median FI, and hence the reproducibility of interventional radiology RCTs, is low compared to other medical fields, with some having a FI of 1, which should be interrupted cautiously.
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Affiliation(s)
- Assala Aslan
- Department of Radiology and Interventional Radiology, Ochsner-Louisiana State University, Shreveport, United States
| | - Christopher Stevens
- Department of Radiology and Interventional Radiology, Ochsner-Louisiana State University, Shreveport, United States
| | - Amro Saad Aldine
- Department of Radiology and Interventional Radiology, Ochsner-Louisiana State University, Shreveport, United States
| | - Ahmed Mamilly
- Department of Radiology and Interventional Radiology, Ochsner-Louisiana State University, Shreveport, United States
| | - Luis De Alba
- Department of Radiology and Interventional Radiology, Ochsner-Louisiana State University, Shreveport, United States
| | - Octavio Arevalo
- Department of Radiology and Interventional Radiology, Ochsner-Louisiana State University, Shreveport, United States
| | - Chaitanya Ahuja
- Department of Radiology and Interventional Radiology, Ochsner-Louisiana State University, Shreveport, United States
| | - Hugo H. Cuellar
- Department of Radiology and Interventional Radiology, Ochsner-Louisiana State University, Shreveport, United States
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12
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Kingsmore DB, Stevenson KS, Thomson PC, Kasthuri R, Knight S, Jackson A, Hussey K, Richarz S, Isaak A. Pre-emptive or reactive treatment, angioplasty or stent-graft? The outcome for interventions for venous stenosis in early-cannulation arteriovenous grafts. J Vasc Access 2023; 24:253-260. [PMID: 34219517 DOI: 10.1177/11297298211029413] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Early-cannulation arteriovenous grafts (ecAVG) have good initial patency, but frequent episodes of reintervention for venous stenosis (VS) and thrombosis limit their use. Stent grafts (SG) have shown promise in reducing re-interventions and improving functional patency for dysfunctional ecAVG and recurrent VS. There is little data on the impact of stent grafts as the first elective procedure for VS. The aim of this study was to determine firstly, if treating VS whilst asymptomatic has a better outcome than treating after presentation with thrombosis; and secondly, to determine the best initial treatment for asymptomatic VS: SG or angioplasty. METHODS A retrospective study was performed of 259 ecAVG with a sutured anastomosis. The case-mix and outcomes of 153 who presented with VS was analysed by presentation (elective at surveillance or emergency following thrombosis), and then for only elective patients, by treatment (SG vs angioplasty). RESULTS There was no significant difference in case-mix and time to presentation by mode of presentation (100 elective and 53 with thrombosis) other than a higher rate of pro-thrombotic disorders in thrombosed ecAVG. Thrombosed ecAVG had poorer outcomes with increased re-intervention rates and thrombosis in the following year, and reduced long-term functional patency. In patients presenting electively, primary SG rather than angioplasty led to significantly reduced thrombosis rates, a longer time to re-intervention in the following year, and superior long-term functional patency. The use of SG was the same in both groups. Both the mode of presentation and the type of intervention performed were independently predictive of a poorer subsequent functional patency. CONCLUSIONS Primary elective stent-grafting may be the optimal strategy to reducing maintenance costs with ecAVG.
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Affiliation(s)
- David B Kingsmore
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK.,Vascular and Endovascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Karen S Stevenson
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Peter C Thomson
- Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Ram Kasthuri
- Interventional Radiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Stephen Knight
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Andrew Jackson
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Keith Hussey
- Vascular and Endovascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Sabine Richarz
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK.,Vascular and Endovascular Surgery, University Hospital, Aarau-Basel, Switzerland
| | - Andrej Isaak
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK.,Vascular and Endovascular Surgery, University Hospital, Aarau-Basel, Switzerland
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13
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Shaikh A, Albalas A, Desiraju B, Dwyer A, Haddad N, Almehmi A. The role of stents in hemodialysis vascular access. J Vasc Access 2023; 24:107-116. [PMID: 33993804 PMCID: PMC10896277 DOI: 10.1177/11297298211015069] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Vascular access is the Achilles' heel of dialysis therapy among patient with end stage kidney disease. The development of neointimal hyperplasia and subsequent stenosis is common in vascular access and is associated with significant morbidity. Percutaneous transluminal angioplasty using balloon inflation was the standard therapy of these lesions. However, the balloon-based approaches were associated with poor vascular access patency rate necessitating new inventions. It is within this context that different types of stents were developed in order to improve the overall dialysis vascular access functionality. In this article, we review the available literature regarding the use of stents in treating dialysis vascular access stenotic lesions. Further, we review the major clinical trials of stent use in different anatomic locations and in different clinical scenarios.
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Affiliation(s)
- Aisha Shaikh
- Department of Medicine, James J. Peters VA Medical Center, Bronx, NY, USA
| | - Alian Albalas
- Department of Biology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Brinda Desiraju
- Department of Medicine, SUNY Downstate School of Medicine, Brooklyn, NY, USA
| | - Amy Dwyer
- Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Nabil Haddad
- Department of Medicine, The Ohio State University Medical Center, Columbus, OH, USA
| | - Ammar Almehmi
- Department of Medicine and Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
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14
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Pourmoussa AJ, Mahendra AM, Peña CS, Powell A, Schiro BJ, Herrera R, Katzen BT, Narayanan G, Niekamp AS, Gandhi RT. Stent Graft Outcomes in Dialysis Circuits: A Review of Clinical Trials and Literature. Semin Intervent Radiol 2022; 39:75-81. [PMID: 35210736 PMCID: PMC8856768 DOI: 10.1055/s-0042-1742390] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
End-stage renal disease is a prevalent medical condition causing significant problems as the majority of patients are being treated with dialysis. While dialysis provides a means to compensate for the renal impairment, arteriovenous grafts and fistulas are often complicated by neointimal hyperplasia, loss of primary patency, and graft failure. Over the last decade, stent grafts have emerged as an alternative to balloon angioplasty and bare metal stents for revascularization in the event of arteriovenous graft occlusion or stenosis. Several randomized controlled trials have investigated the efficacy of stent grafts compared with balloon angioplasty for improving the function and durability of dialysis circuits. In this review, we present a comprehensive review of clinical trials. Stent grafts appear to offer increased primary patency over balloon angioplasty in the treatment of dialysis circuit stenosis. However, there is generally no significant difference between the two treatment modalities on other clinically relevant measures like complication rates and overall survival.
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Affiliation(s)
- Austin J. Pourmoussa
- Department of Interventional Radiology, Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida,Address for correspondence Austin J. Pourmoussa, MD Department of Interventional Radiology, Miami Cardiac and Vascular Institute, Baptist Health South Florida8900 N Kendall Dr, Miami, FL 33176
| | - Ashwin M. Mahendra
- Department of Interventional Radiology, Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida
| | - Constantino S. Peña
- Department of Interventional Radiology, Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida,Department of Interventional Radiology, Florida International University Herbert Wertheim College of Medicine, Miami, Florida
| | - Alex Powell
- Department of Interventional Radiology, Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida
| | - Brian J. Schiro
- Department of Interventional Radiology, Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida
| | - Raul Herrera
- Department of Interventional Radiology, Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida,Department of Medical and Health Science Research, Florida International University Herbert Wertheim College of Medicine, Miami, Florida
| | - Barry T. Katzen
- Department of Interventional Radiology, Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida,Department of Interventional Radiology, Florida International University Herbert Wertheim College of Medicine, Miami, Florida
| | - Govindarajan Narayanan
- Department of Interventional Radiology, Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida,Department of Interventional Radiology, Florida International University Herbert Wertheim College of Medicine, Miami, Florida
| | - Andrew S. Niekamp
- Department of Interventional Radiology, Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida
| | - Ripal T. Gandhi
- Department of Interventional Radiology, Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, Florida,Department of Interventional Radiology, Florida International University Herbert Wertheim College of Medicine, Miami, Florida
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15
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Dolmatch B, Waheed U, Balamuthusamy S, Hoggard J, Settlage R. Prospective, Multi-center Clinical Study of the Covera Vascular Covered Stent in the Treatment of Stenosis at the Graft-Vein Anastomosis of Dysfunctional Hemodialysis Access Grafts. J Vasc Interv Radiol 2022; 33:479-488.e3. [DOI: 10.1016/j.jvir.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 01/12/2022] [Accepted: 02/06/2022] [Indexed: 10/19/2022] Open
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16
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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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17
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Ng B, Fugger M, Onakpoya IJ, Macdonald A, Heneghan C. Covered stents versus balloon angioplasty for failure of arteriovenous access: a systematic review and meta-analysis. BMJ Open 2021; 11:e044356. [PMID: 34108161 PMCID: PMC8191614 DOI: 10.1136/bmjopen-2020-044356] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Patients with end-stage renal disease may require arteriovenous (AV) access in the form of arteriovenous fistulae (AVFs) or arteriovenous grafts (AVGs) for haemodialysis. AV access dysfunction requires intervention such as plain balloon angioplasty or covered stents to regain patency. AIM To systematically review and meta-analyse the patency outcomes of covered stents in failing haemodialysis AV access, compared with balloon angioplasty. METHODS The review was first registered on the International Prospective Register of Systematic Reviews (CRD42018069955) before data collection. We searched six electronic databases to identify relevant randomised controlled trials (RCTs) up until August 2020, without language restriction. Two reviewers assessed the suitability and quality of studies for inclusion using the Consolidated Standards of Reporting Trials guidelines. We meta-analysed data using a random-effects model. RESULTS We included seven studies including 1147 patients in the systematic review, of which 867 had AVGs and 280 had AVFs. One study was an ongoing RCT. In the meta-analyses, we assessed patients with failing AVGs only. Overall risk of bias was moderate. Covered stents were associated with lower loss of patency versus angioplasty alone at 6, 12 and 24 months (OR 4.48, 95% CI 1.98 to 10.14, p<0.001; OR 4.07, 95% CI 1.74 to 9.54, p=0.001; OR 2.24, 95% CI 1.17 to 4.29, p=0.01, respectively). Covered stents afforded superior access circuit primary patency compared with angioplasty alone at 6 and 12 months (OR 1.91, 95% CI 1.31 to 2.80, p<0.001; OR 1.97, 95% CI 1.14 to 3.41, p=0.02, respectively). This was not significant at 24 months. There was no significant difference in loss of secondary patency between groups at 12 or 24 months (OR 0.74, 95% CI 0.45 to 1.23, p=0.25; OR 0.67, 95% CI 0.29 to 0.154, p=0.34, respectively). CONCLUSION Our results support use of covered stents over angioplasty alone, at 6, 12 and 24 months in failing AVGs. Further clinical trials are warranted.
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Affiliation(s)
- Benjamin Ng
- Medical Sciences Division, University of Oxford, Oxford, UK
| | - Magnus Fugger
- Medical Sciences Division, University of Oxford, Oxford, UK
| | - Igho Jovwoke Onakpoya
- Department of Continuing Education, University of Oxford, Oxford, UK
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
| | - Andrew Macdonald
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Carl Heneghan
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
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18
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Matsuoka Y, Iida O, Suemitsu K, Oka K, Ota N, Izumi M. Use of a fluoropolymer-based paclitaxel-eluting stent for arteriovenous graft outflow vein stenosis in hemodialysis patients. J Vasc Surg Cases Innov Tech 2021; 7:326-331. [PMID: 34041421 PMCID: PMC8144112 DOI: 10.1016/j.jvscit.2021.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 03/25/2021] [Indexed: 11/04/2022] Open
Abstract
We implanted a fluoropolymer-based paclitaxel-eluting stent (FP-PES) in four hemodialysis patients with refractory outflow venous stenosis of their arteriovenous graft. The mean observation period after FP-PES implantation was 11.5 ± 4.7 months (range, 7.0-18.0 months). After FP-PES implantation, the patients were evaluated by ultrasound every 3 months. No of the patients experienced neointimal hyperplasia in the stents during the observation period, and no reintervention was performed. FP-PESs could be an attractive alternative to percutaneous transluminal angioplasty for patients with refractory outflow venous stenosis of arteriovenous hemodialysis grafts.
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19
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Vachharajani TJ, Taliercio JJ, Anvari E. New Devices and Technologies for Hemodialysis Vascular Access: A Review. Am J Kidney Dis 2021; 78:116-124. [PMID: 33965296 DOI: 10.1053/j.ajkd.2020.11.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 11/09/2020] [Indexed: 11/11/2022]
Abstract
In the United States, hemodialysis remains the most common treatment modality for kidney failure, chosen by almost 90% of incident patients. A functioning vascular access is key to providing adequate hemodialysis therapy. Recently, major innovations in devices and technology for hemodialysis vascular access care have rapidly changed the landscape. Novel endovascular devices for creation of arteriovenous fistulas may offer a solution to the barriers encountered in initiating maintenance hemodialysis with a permanent vascular access rather than a central venous catheter (CVC). Furthermore, in the prevalent hemodialysis population, the minimally invasive endovascular arteriovenous fistula procedure should help improve long wait times for vascular access creation, which remains a major barrier to reducing CVC dependence. Bioengineered grafts are being developed and may offer another option to polytetrafluoroethylene grafts. Early studies with these biocompatible grafts are promising, as additional studies continue to evaluate their clinical outcomes in comparison to cryopreserved or synthetic options. Prolonging the vascular access patency with appropriate use of devices such as drug-coated balloons and stent grafts may complement the novel techniques of creating arteriovenous access. Finally, innovative solutions to treat stenosed and occluded thoracic central veins can provide an approach to creating a vascular access and allow patients with exhausted vasculature to remain on hemodialysis. The robust developments in hemodialysis vascular access are likely to change practice patterns in the near future.
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Affiliation(s)
- Tushar J Vachharajani
- Department of Nephrology and Hypertension, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH.
| | - Jonathan J Taliercio
- Department of Nephrology and Hypertension, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Evamaria Anvari
- Department of Nephrology and Hypertension, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH; Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
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20
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Manov JJ, Mohan PP, Vazquez-Padron R. Arteriovenous fistulas for hemodialysis: Brief review and current problems. J Vasc Access 2021; 23:839-846. [PMID: 33818180 DOI: 10.1177/11297298211007720] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The number of people worldwide living with end-stage renal disease is increasing. Arteriovenous fistulas are the preferred method of vascular access in patients who will require hemodialysis. As the number of patients with arteriovenous fistulas grows, the role of physicians who intervene who maintain and salvage these fistulas will grow in importance. This review aims to familiarize practitioners with the rationale for arteriovenous fistula creation, the detection of fistula dysfunction, and the state of the art on fistula maintenance and preservation. Current controversies are briefly reviewed.
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Affiliation(s)
- John J Manov
- Department of Radiology, University of Miami, Miami, FL, USA
| | - Prasoon P Mohan
- Department of Interventional Radiology, University of Miami, Miami, FL, USA
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21
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Girault A, Pellenc Q, Roussel A, Senemaud J, Cerceau P, Maggiori L, Huguet A, Corcos O, Ben Abdallah I, Castier Y. Midterm results after covered stenting of the superior mesenteric artery. J Vasc Surg 2021; 74:902-909.e3. [PMID: 33684478 DOI: 10.1016/j.jvs.2021.02.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 02/19/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Despite the continuing controversy of covered stents (CS) vs bare metal stents, the use of CS in mesenteric occlusive disease (MOD) has been recommended by expert centers. The aim of this study was to report midterm results with CS of the superior mesenteric artery. METHODS Between January 2014 and October 2019, patients with MOD with a severe atheromatous stenosis or occlusion of the superior mesenteric artery treated by mesenteric CS were included. Clinical presentation included both acute mesenteric ischemia (AMI), chronic mesenteric ischemia, and asymptomatic patients planned for major surgery. Demographics, procedure details, and follow-up data were prospectively collected and retrospectively reviewed. Study end points included primary patency, primary assisted patency, and secondary patency. RESULTS During the study period, 86 patients (mean age, 70 ± 9 years; 57% males) were included. Clinical presentation was AMI (n = 42 [49%]), chronic mesenteric ischemia (n = 31 [36%]), and asymptomatic (n = 13 [15%]). The technical success rate was 97%. A total of 96 stents were implanted, including 86 proximal CS (Advanta V12, n = 73; Lifestream, n = 13). The mean length and mean diameter of the CS were 31.5 ± 6.3 mm and 6.9 ± 0.5 mm, respectively. Additional distal bare metal stents were used in 10 patients (12%) to overcome a kinking (n = 9) or a dissection (n = 1) downstream of the CS. All postoperative deaths occurred in patients with AMI (n = 11, 13%). During a median follow-up of 15.6 months (95% confidence interval [CI], 15.6 ± 3.6 months), 12 patients (14%) underwent reinterventions for either stent misplacement (n = 3), stent recoil (n = 3), stent thrombosis (n = 2), de novo stenosis at the distal edge of the CS (n = 2), or gastric ischemia (n = 1). At 1 year, overall the primary patency, primary assisted patency, and secondary patency rates were 83% (95% CI, 83% ± 9%), 99% (95% CI, 99% ± 3%), and 99% (95% CI, 99% ± 3%), respectively. At 2 years, the overall primary patency, primary assisted patency, and secondary patency rates were 76% (95% CI, 76% ± 13%), 95% (95% CI, 95% ± 8%) and 95% (95% CI, 95% ± 8%), respectively. CONCLUSIONS Mesenteric CS provide very satisfactory midterm results in patients with MOD, with an excellent primary assisted patency rate at 2 years, at the price of a significant reintervention rate.
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Affiliation(s)
- Antoine Girault
- Service de chirurgie Vasculaire et Thoracique, Hôpital Bichat, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France.
| | - Quentin Pellenc
- Service de chirurgie Vasculaire et Thoracique, Hôpital Bichat, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Arnaud Roussel
- Service de chirurgie Vasculaire et Thoracique, Hôpital Bichat, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Jean Senemaud
- Service de chirurgie Vasculaire et Thoracique, Hôpital Bichat, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Pierre Cerceau
- Service de chirurgie Vasculaire et Thoracique, Hôpital Bichat, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Léon Maggiori
- Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Service de chirurgie viscérale, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Audrey Huguet
- Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Service de gastro-entérologie et assistance nutritive, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Olivier Corcos
- Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Service de gastro-entérologie et assistance nutritive, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Iannis Ben Abdallah
- Service de chirurgie Vasculaire et Thoracique, Hôpital Bichat, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
| | - Yves Castier
- Service de chirurgie Vasculaire et Thoracique, Hôpital Bichat, Hôpital Beaujon, AP-HP, Université de Paris, Paris, France; Structure d'Urgences Vasculaire Intestinale (SURVI), Hôpital Beaujon, AP-HP, Université de Paris, Paris, France
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Cai Z, Ran M, Song J, Zhen W, Li M. Imaging Diagnosis and Interventional Treatment for Hepatocellular Carcinoma Combined with Arteriovenous Fistula. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:6651236. [PMID: 33747418 PMCID: PMC7952172 DOI: 10.1155/2021/6651236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/11/2021] [Accepted: 02/23/2021] [Indexed: 11/25/2022]
Abstract
In order to explore the imaging diagnosis methods and interventional treatment effects of hepatocellular carcinoma combined with hepatic arteriovenous fistula (HAVF), a total of 120 patients, who were diagnosed as hepatic carcinoma with arteriovenous shunting and underwent medical imaging diagnosis and interventional surgery therapy at a designated hospital by this study from December 2014 to December 2018, were chosen as study subjects. Digital subtraction angiography was performed to analyze the imaging features of hepatocellular carcinoma combined with HAVF in each patient; then, according to these imaging diagnosis results, gelatin sponge or coil was used to block the fistula; mitomycin, carboplatin powder, and lipiodol mixed emulsion was combined or separately utilized for hepatic tumor embolization, in which iodized oil embolization chemotherapy was used for patients with mild paralysis; gelatin sponge granule embolization chemotherapy was used for moderate paralysis patients at their first intervention, and, after about 1 month, if the sputum disappeared, iodized oil embolization was used again; and hepatic arterial infusion chemotherapy was used only for patients with severe paralysis. The results show that the central type of HAVF is characterized by early angiography of portal vein and large branches and tumor staining after portal vein's angiography; the peripheral type of HAVF is characterized by portal vein branching in hepatic tumor and double rail sign accompanied by the arterial branch; 112 cases of patients completed embolization chemotherapy; 8 cases of patients only received chemotherapy perfusion; in 109 cases of patients sputum disappeared or shunt decreased at first treatment; and in 113 cases of patients iodine oil was well deposited or the tumor was stably reduced; most of the symptoms of refractory ascites, diarrhea, and upper gastrointestinal bleeding were controlled or improved, and there were no complications such as pulmonary embolism and hepatic failure. Therefore, HAVF increases the difficulty of interventional therapy, but, as long as the positive and appropriate treatment measures are taken, it can still achieve better curative effect without serious complications, which can effectively alleviate the clinical symptoms of patients and improve the quality of life of patients. The results of this study provide a reference for the further researches on imaging diagnosis and interventional treatment for hepatocellular carcinoma combined with arteriovenous fistula.
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Affiliation(s)
- Zheng Cai
- The Second Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Maohui Ran
- Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Jiantao Song
- The Second Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Wenrui Zhen
- The Second Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
| | - Mingjian Li
- The Second Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou, China
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Bittl JA. Dialysis access intervention: Techniques for the interventional cardiologist. Prog Cardiovasc Dis 2021; 65:84-88. [PMID: 33587962 DOI: 10.1016/j.pcad.2021.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/02/2021] [Indexed: 11/16/2022]
Abstract
Interventional cardiologists who treat malfunctioning hemodialysis accesses play an important role in the life of patients with end-stage kidney disease (ESKD). By collaborating with interventional nephrologists who currently perform the bulk of routine access angiographic procedures, interventional cardiologists can fill an important gap in the care of ESKD patients by performing urgent or emergent procedures that fall outside the schedule of an outpatient interventional nephrology laboratory to ensure that hemodialysis patients will not miss a hemodialysis session or get a temporary catheter. This paper reviews the pathophysiology of dialysis access failure and illustrates the catheter-based approaches used by interventional cardiologists to treat malfunctioning dialysis accesses.
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Affiliation(s)
- John A Bittl
- Interventional Cardiology Program, AdventHealth Ocala, Ocala, Florida 34474, United States of America.
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Tan CW, Tan RY, Pang SC, Tng ARK, Tang TY, Zhuang KD, Chua JME, Tay KH, Chong TT, Tan CS. Single-Center Prospective Pilot Study of Sirolimus Drug-Coated Balloon Angioplasty in Maintaining the Patency of Thrombosed Arteriovenous Graft. J Vasc Interv Radiol 2020; 32:369-375. [PMID: 33334667 DOI: 10.1016/j.jvir.2020.11.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/23/2020] [Accepted: 11/05/2020] [Indexed: 01/09/2023] Open
Abstract
PURPOSE To investigate the use of a sirolimus drug-coated balloon (DCB) in the management of a thrombosed arteriovenous graft (AVG). MATERIALS AND METHODS A single-center prospective pilot study was conducted between October 2018 and October 2019. Twenty patients (age = 67.0 years ± 10; male = 35%; mean time on dialysis = 31 months) with thrombosed upper limb AVG were enrolled. After successful pharmacomechanical thrombectomy and adequate treatment of the graft vein junction, sirolimus DCB angioplasty was performed at the graft vein junction. The patients were followed-up for 6 months, and all adverse events occurring during the study period were recorded. RESULTS The primary circuit patency rates at 3 and 6 months were 76% and 65%, respectively, while the assisted-primary circuit patency rates at 3 and 6 months were 82% and 65%, respectively. The 3- and 6-month secondary circuit patency rates were 88% and 76%, respectively. Using Kaplan-Meier analyses, the estimated mean primary, assisted-primary, and secondary patencies were 285 days (95% confidence interval (CI) = 194-376 days), 319 days (95% CI = 221-416 days), and 409 days (95% CI = 333-485 days). No adverse event directly related to sirolimus DCB use was observed. CONCLUSIONS The results of this pilot study suggest that the application of sirolimus DCB at the graft vein junction after the successful thrombectomy of AVG may be a feasible option to improve patency outcomes.
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Affiliation(s)
- Chee Wooi Tan
- Department of Renal Medicine, Singapore General Hospital, Academia, Level 3, 20 College Road, Singapore 169856
| | - Ru Yu Tan
- Department of Renal Medicine, Singapore General Hospital, Academia, Level 3, 20 College Road, Singapore 169856.
| | - Suh Chien Pang
- Department of Renal Medicine, Singapore General Hospital, Academia, Level 3, 20 College Road, Singapore 169856
| | - Alvin Ren Kwang Tng
- Department of Renal Medicine, Singapore General Hospital, Academia, Level 3, 20 College Road, Singapore 169856
| | - Tjun Yip Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Kun Da Zhuang
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - Jasmine Ming Er Chua
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - Kiang Hiong Tay
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore
| | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Chieh Suai Tan
- Department of Renal Medicine, Singapore General Hospital, Academia, Level 3, 20 College Road, Singapore 169856
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Gong M, Zhou Y, Zhao B, Kong J, He X. Efficacy of stent-graft placement to salvage central vein stents with recalcitrant restenosis in patients with arteriovenous fistulas. Semin Dial 2020; 33:382-387. [PMID: 32748477 DOI: 10.1111/sdi.12908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 03/09/2020] [Accepted: 07/14/2020] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to determine the effectiveness and permanency of stent-graft placement to salvage stents with recalcitrant restenosis due to central vein stenosis (CVS). Between May 2014 and February 2016, VIABAHN stent-grafts were deployed in patients with functioning arteriovenous (AV) fistulas who underwent previous bare metal stent (BMS) placement and had recalcitrant stent restenosis that did not respond to percutaneous transluminal angioplasty (PTA). Surveillance was carried out at 3, 6, 12, 18, and 24 months with diagnostic fistulography. Fourteen patients initially underwent 15 BMS placements. In the follow-up period (range, 118-976 days), patients presented with symptomatic venous hypertension; subsequently, a total of 52 unsuccessful repeat PTAs for BMS restenosis were undertaken, and the median primary access survival of PTAs was 66 ± 43 days. For salvage, 14 stent-grafts were placed in segments with recalcitrant restenosis of a CVS stent. Within 1.25 ± 0.72 days after stent-graft placement, patients who initially presented with symptomatic venous hypertension reported complete resolution. The median primary access survival (mean, 1183 ± 312 days) was longer than PTAs alone (P < .01). No major or minor complications were associated with stent-graft deployment or any of the subsequent interventions in the study period. The primary patency rate at 6, 12, and 18 months was 100%, and it was 85.7% at 24 months. The secondary access patency rate was 92.9% at 24 months. In conclusion, stent-graft placement to salvage CVS stents with recalcitrant restenosis in patients with AV fistulas is safe and effective if PTAs fails to maintain luminal patency.
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Affiliation(s)
- Maofeng Gong
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, P.R. China
| | - Yangyi Zhou
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, P.R. China
| | - Boxiang Zhao
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, P.R. China
| | - Jie Kong
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, P.R. China
| | - Xu He
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, P.R. China
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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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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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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: 920] [Impact Index Per Article: 230.0] [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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Cline BC, Gage SM, Ronald J, Pabon-Ramos WM, Dillavou ED, Smith TP, Lawson JH, Kim CY. Treatment of Arm Swelling in Hemodialysis Patients with Ipsilateral Arteriovenous Access and Central Vein Stenosis: Conversion to the Hemodialysis Reliable Outflow Graft versus Stent Deployment. J Vasc Interv Radiol 2020; 31:243-250. [DOI: 10.1016/j.jvir.2019.06.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 06/11/2019] [Accepted: 06/13/2019] [Indexed: 11/30/2022] Open
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30
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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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31
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Nikolopoulos GK, Yiallourou AI, Argyriou C, Bonovas S, Georgiadis GS, Lazarides MK. Short Term Success of Treatments to Salvage Thrombosed or Failing Synthetic Arteriovenous Grafts in End Stage Renal Disease: A Systematic Review and Network Meta-Analysis of Randomised Controlled Trials. Eur J Vasc Endovasc Surg 2019; 58:921-928. [DOI: 10.1016/j.ejvs.2019.06.495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 06/24/2019] [Accepted: 06/26/2019] [Indexed: 11/17/2022]
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Madden NJ, Dougherty MJ, Troutman DA, Maloni K, Calligaro KD. Site of service influence on stent use for hemodialysis access interventions. J Vasc Surg 2019; 71:1653-1661. [PMID: 31708303 DOI: 10.1016/j.jvs.2019.06.219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 06/24/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE With rising health care spending in the United States, the Centers for Medicare and Medicaid Services (CMS) in recent years attempted to use reimbursement rates to influence use of less expensive care sites for covered patients, such as ambulatory surgery centers (ASCs) and office-based laboratories (OBLs), in lieu of hospital service sites. It has been suggested that cost savings have not been realized because of more procedures being performed by physicians with ownership interests in nonhospital facilities. CMS adopted massive reimbursement changes for 2019 OBL and ASC-based procedures, which reduced dialysis access angioplasty reimbursement in the ASC setting by 50%, whereas facility reimbursement for stenting increased by 33% above prior levels. The clinical utility of adjunctive stenting in treating dialysis access stenosis remains controversial and highly discretionary. As a vascular group performing such procedures in both a hospital and nonhospital facility in which we have equity interest, we reviewed our use of stents in dialysis access procedures both in the hospital and in the ASC/OBL to determine whether site of service affected stent use. METHODS A retrospective review of a prospectively maintained database was performed from 2014 to 2018. All patients undergoing dialysis access angiography with angioplasty and adjunctive stent placement at our OBL (later ASC) and our primary hospital were included in the study. RESULTS There were 961 angioplasty or stent procedures performed for dialysis accesses between the two sites, 564 (58.7%) in the hospital setting and 397 (41.3%) at the OBL/ASC. There was a significant difference in race and age between the two sites, with younger, minority patients more frequently being treated in the hospital and older, white patients more likely to be treated in the ambulatory setting; 153 (27.1%) underwent adjunctive stent placement in the hospital and 127 (32.0%) in the ambulatory setting (P = .09). CONCLUSIONS Whereas financial incentives have not yet had an appreciable influence on stent use for dialysis access within previous reimbursement paradigms, the dramatic changes recently adopted by CMS may well alter this dynamic and could lead to substantially higher overall costs without proven clinical advantage. Interventionalists may be incentivized to add stents when performing balloon angioplasty in ASCs. With high failure and reintervention rates and increasingly expensive adjuncts (drug-coated balloons and stents, covered stents), the cost implications of attempts to incentivize interventionalists toward a specific type of procedure or site of care are substantial, and unintended negative consequences are likely to occur.
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Affiliation(s)
- Nicholas J Madden
- Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, Pa.
| | | | | | - Krystal Maloni
- Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, Pa
| | - Keith D Calligaro
- Section of Vascular Surgery, Pennsylvania Hospital, Philadelphia, Pa
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Macchi E, Fontana F, Beneventi A, Curti M, Tagliaferri C, Casamassima N, Coppola A, Piffaretti G, Tozzi M, Genovese EA, Piacentino F. Efficacy of Primary Stent-Graft Placement in the Treatment of Vascular Access Graft Outflow Tract Stenosis. Vasc Endovascular Surg 2019; 54:25-35. [PMID: 31537181 DOI: 10.1177/1538574419873176] [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: 11/16/2022]
Abstract
PURPOSE The aim of this study is to present our personal experience using covered nitinol stent-graft in the treatment of outflow tract stenosis of arteriovenous grafts (AVGs) for hemodialysis access. MATERIALS AND METHODS Between May 2015 and October 2017, we retrospectively evaluated 36 (24 males, 12 females; mean age: 65.6 years) patients with AVGs on hemodialysis who underwent percutaneous angioplasty followed by endovascular stent-graft deployment for the treatment of stenosis of the venous outflow of the AVG. Indication for treatment included early restenosis (<3 months after previous percutaneous transluminal angioplasty [PTA]), long stenosis (stenoses >50% extending for a length >5 cm), and recoil of the stenosis after PTA performed with a noncompliant high-pressure balloon. Of 36 patients, 27 (75%) required surgical thrombectomy prior to endovascular procedure. Technical success, clinical success, primary and secondary patency, and safety were evaluated. RESULTS Technical success was 100%, and clinical success was 94.4%. Primary patency was 94.4%, 72.2%, 63%, 45.9%, and 45.9% at 1, 3, 6, 12, and 18 months (average: 215 days, range: 9-653 days); secondary patency was 94.4% and 86.1% at 1 and 3 months; 80.4% at 6, 12, and 18 months; and 53.6% at 24 months (average: 276.8 days, range: 9-744 days). No deaths were registered. CONCLUSIONS In selected cases, the use of stent-graft represents an effective and safe solution for the treatment of stenotic complications of the venous outflow of AVGs, even in the setting of access thrombosis.
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Affiliation(s)
- Edoardo Macchi
- Department of Diagnostic and Interventional Radiology, University of Insubria, ASST Settelaghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Federico Fontana
- Department of Diagnostic and Interventional Radiology, University of Insubria, ASST Settelaghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Alessandro Beneventi
- Department of Diagnostic and Interventional Radiology, University of Insubria, ASST Settelaghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Marco Curti
- Department of Diagnostic and Interventional Radiology, University of Insubria, ASST Settelaghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Chiara Tagliaferri
- Department of Diagnostic and Interventional Radiology, University of Insubria, ASST Settelaghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Nicola Casamassima
- Department of Diagnostic and Interventional Radiology, University of Insubria, ASST Settelaghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Andrea Coppola
- Department of Diagnostic and Interventional Radiology, University of Insubria, ASST Settelaghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Gabriele Piffaretti
- Department of Vascular Surgery, University of Insubria, ASST Settelaghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Matteo Tozzi
- Department of Vascular Surgery, University of Insubria, ASST Settelaghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Eugenio Annibale Genovese
- Department of Diagnostic and Interventional Radiology, University of Insubria, ASST Settelaghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Filippo Piacentino
- Department of Diagnostic and Interventional Radiology, University of Insubria, ASST Settelaghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
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Yilmazsoy Y, Ozyer U. Long-term results of endovascular treatment for arteriovenous dialysis access thrombosis in 143 patients: A single center experience. J Vasc Access 2019; 20:545-552. [DOI: 10.1177/1129729819865808] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective:This study aimed to determine the long-term patency duration and rate of thrombosis of autologous arteriovenous fistulas and synthetic grafts treated with endovascular methods in a large patient population.Methods:A total of 144 arteriovenous accesses (37 radiocephalic, 51 brachiobasilic, 41 brachiocephalic, and 15 femorofemoral) from 143 patients were included in the study. A total of 304 endovascular thrombolytic treatment procedures were performed for 94 (65%) arteriovenous fistula and 50 (35%) arteriovenous graft accesses.Results:The procedural technical success rate was 98.7%. The mean follow-up duration was 32.5 (range, 3–132) months. The primary patency rates for arteriovenous fistulas and arteriovenous grafts were 78% and 78% at 6 months, 66% and 63% at 1 year, and 45% and 0% at 36 months, respectively. The assisted primary patency rates for arteriovenous fistulas and arteriovenous grafts were 82% and 84% at 6 months, 71% and 69% at 1 year, 51% and 29% at 36 months, and 30% and 1% at 60 months, respectively. The secondary patency rates for arteriovenous fistulas and arteriovenous grafts were 94% and 93% at 6 months, 85% and 85% at 1 year, 58% and 59% at 36 months, and 47% and 48% at 60 months, respectively.Conclusion:Although the primary patency durations for arteriovenous fistulas were better after endovascular thrombolytic treatment than those for arteriovenous grafts, the long-term outcomes of assisted primary and secondary patency durations after repeated procedures were similar for both types of arteriovenous accesses.
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Affiliation(s)
| | - Umut Ozyer
- Department of Radiology, Faculty of Medicine, Baskent University, Ankara, Turkey
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Pawar P, Sharma A, Ayyappan MK, Mathur K, Jagan J, Raju R. Stent Graft Placement for Treatment of Prosthetic Graft Outflow Stenosis, a Viable Long-term Solution: A Case Report. Indian J Nephrol 2019; 29:211-213. [PMID: 31142972 PMCID: PMC6521774 DOI: 10.4103/ijn.ijn_135_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Failing prosthetic grafts in patients undergoing hemodialysis is a common problem. Balloon angioplasty is the first line in treating these stenoses, but it is associated with poor patency rates due to recoil and subsequent restenosis. The use of stent graft implantation has shown very promising early and long-term results as per recent literature. We describe a case of arteriovenous graft outflow stenosis, which led to complete thrombosis of the graft, which was rescued by surgical thrombectomy and stent graft placement across the venous end of the anastomosis with good results.
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Affiliation(s)
- Pranay Pawar
- Department of Vascular Surgery, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India
| | - Achintya Sharma
- Department of Vascular Surgery, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India
| | - M K Ayyappan
- Department of Vascular Surgery, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India
| | - Kapil Mathur
- Department of Vascular Surgery, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India
| | - Jithin Jagan
- Department of Vascular Surgery, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India
| | - Radhakrishnan Raju
- Department of Vascular Surgery, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India
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Mohr BA, Sheen AL, Roy-Chaudhury P, Schultz SR, Aruny JE. Clinical and Economic Benefits of Stent Grafts in Dysfunctional and Thrombosed Hemodialysis Access Graft Circuits in the REVISE Randomized Trial. J Vasc Interv Radiol 2019; 30:203-211.e4. [PMID: 30717951 DOI: 10.1016/j.jvir.2018.12.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/29/2018] [Accepted: 12/02/2018] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To compare reinterventions and associated costs to maintain arteriovenous graft hemodialysis access circuits after rescue with percutaneous transluminal angioplasty (PTA), with or without concurrent Viabahn stent grafts, over 24 months. MATERIALS AND METHODS This multicenter (n = 30 sites) study evaluated reintervention number, type, and cost in 269 patients randomized to undergo placement of stent grafts or PTA alone. Outcomes were 24-month average cumulative number of reinterventions, associated costs, and total costs for all patients and in 4 groups based on index treatment and clinical presentation (thrombosed or dysfunctional). RESULTS Over 24 months, the patients in the stent graft arm had a 27% significant reduction in the average number of reinterventions within the circuit compared to the PTA arm (3.7 stent graft vs 5.1 PTA; P = .005) and similar total costs ($27,483 vs $28,664; P = .49). In thrombosed grafts, stent grafts significantly reduced the number of reinterventions (3.7 stent graft vs 6.2 PTA; P = .022) and had significantly lower total costs compared to the PTA arm ($30,329 vs $37,206; P = .027). In dysfunctional grafts, no statistical difference was observed in the number of reinterventions or total costs (3.7 stent graft vs 4.4 PTA; P = .12, and $25,421 stent graft and $22,610 PTA; P = .14). CONCLUSIONS Over 24 months, the use of stent grafts significantly reduced the number of reinterventions for all patients, driven by patients presenting with thrombosed grafts. Compared to PTA, stent grafts reduced overall treatment costs for patients presenting with thrombosed grafts and had similar costs for stenotic grafts.
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Affiliation(s)
- Belinda A Mohr
- W. L. Gore & Associates Inc, 2205 West Whispering Wind Drive, Phoenix, AZ 85085.
| | | | - Prabir Roy-Chaudhury
- Department of Medicine and the Arizona Kidney and Vascular Center, University of Arizona Health Sciences, Tucson, Arizona
| | - Scott R Schultz
- Minneapolis Radiology Associates and Minneapolis Vascular Physicians, Plymouth, Minnesota
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Wang T, Wang S, Gu J, Lou W, He X, Chen L, Chen G, Zee C, Chen BT. Transcatheter Thrombolysis with Percutaneous Transluminal Angioplasty Using a Trans-Brachial Approach to Treat Thrombosed Arteriovenous Fistulas. Med Sci Monit 2019; 25:2727-2734. [PMID: 30980711 PMCID: PMC6476234 DOI: 10.12659/msm.915755] [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] [Indexed: 12/24/2022] Open
Abstract
Background Arteriovenous fistulas (AVFs) are used to provide vascular access for hemodialysis in patients with end-stage renal failure. However, stenosis and thrombosis can compromise long-term AVF patency. The objective of this study was to evaluate catheter thrombolysis with percutaneous transluminal angioplasty (PTA), using a trans-brachial approach, for acutely thrombosed AVFs. Material/Methods This retrospective study examined 30 cases of AVF thrombosis treated between January 1, 2015 and January 1, 2017. All patients received transcatheter thrombolysis with PTA using a trans-brachial approach. AVF patency was assessed after 6 months. Results Thrombolysis with PTA was performed at 2 to 72 h after diagnosis of AVF occlusion due to acute thrombosis, and AVF patency was restored in all patients. After 6 months, the primary and secondary patency rates were 76.7% and 93.3%, respectively. For type I stenosis, primary patency was achieved in 10 of 16 patients (62.5%) and secondary patency was achieved in 14 of 16 patients (87.5%). For type II stenosis, primary patency was achieved in 13 of 14 patients (92.9%) and secondary patency was achieved in 14 of 14 patients (100%). Comparing type I and II stenosis, a significant difference was detected in the rates of primary patency (odds ratio=0.909, 95% confidence interval 0.754–1.096, P=0.049), but not secondary patency (P=0.178), after 6 months. Conclusions Our study provides preliminary evidence that catheter-directed thrombolysis with PTA using a trans-brachial approach can achieve high patency rates when used to treat acutely thrombosed AVFs.
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Affiliation(s)
- Tao Wang
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland).,Department of Diagnostic Radiology, City of Hope National Medical Center, Duarte, CA, USA
| | - Shukui Wang
- Central Laboratory, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Jianping Gu
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Wensheng Lou
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Xu He
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Liang Chen
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Guoping Chen
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Chishing Zee
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Bihong T Chen
- Department of Diagnostic Radiology, City of Hope National Medical Center, Duarte, CA, USA
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Kitrou P, Papasotiriou M, Katsanos K, Karnabatidis D, Goumenos DS, Papachristou E. Recent developments in endovascular interventions to sustain vascular access patency in haemodialysis patients. Nephrol Dial Transplant 2018; 34:1994-2001. [DOI: 10.1093/ndt/gfy354] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 10/12/2018] [Indexed: 12/22/2022] Open
Abstract
Abstract
There is amassed evidence regarding the use of endovascular procedures for the treatment of vascular access stenosis and thrombosis. A review was conducted based on available randomized trials, cohort studies and retrospective analyses published after 2000 on endovascular treatment of dysfunctional and thrombosed vascular access, with an aim to illustrate the available device and procedural options. The use of paclitaxel-coated balloons, cutting balloons and covered stents is described in the field of vascular access stenosis. The broad spectrum of available devices and endovascular declotting procedures ranging from thrombolysis to thrombectomy is also discussed. Overall, in this review we demonstrate the increasing role of endovascular procedures in vascular access treatment and the improved patency outcomes provided by the implementation of novel endovascular devices. Moreover, the improvement of post-intervention primary patency rates after endovascular declotting procedures and the shift to more thrombectomy-dependent procedures over time is also highlighted. In conclusion, endovascular treatment of dialysis access stenosis and thrombosis has an established role, owing to the implementation of sophisticated devices, allowing, when needed, the simultaneous treatment of thrombosis and the underlying stenosis.
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Affiliation(s)
- Panagiotis Kitrou
- Interventional Radiology Department, Patras University Hospital, Patras, Greece
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Schmidli J, Widmer MK, Basile C, de Donato G, Gallieni M, Gibbons CP, Haage P, Hamilton G, Hedin U, Kamper L, Lazarides MK, Lindsey B, Mestres G, Pegoraro M, Roy J, Setacci C, Shemesh D, Tordoir JH, van Loon M, ESVS Guidelines Committee, Kolh P, de Borst GJ, Chakfe N, Debus S, Hinchliffe R, Kakkos S, Koncar I, Lindholt J, Naylor R, Vega de Ceniga M, Vermassen F, Verzini F, ESVS Guidelines Reviewers, Mohaupt M, Ricco JB, Roca-Tey R. Editor's Choice – Vascular Access: 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 55:757-818. [DOI: 10.1016/j.ejvs.2018.02.001] [Citation(s) in RCA: 346] [Impact Index Per Article: 57.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Dolmatch B, Hogan A, Ferko N. An Economic Analysis of Stent Grafts for Treatment of Vascular Access Stenosis: Point-of-Care and Medicare Perspectives in the United States. J Vasc Interv Radiol 2018; 29:765-773.e2. [PMID: 29706343 DOI: 10.1016/j.jvir.2018.01.777] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 01/16/2018] [Accepted: 01/17/2018] [Indexed: 01/31/2023] Open
Abstract
PURPOSE To conduct an economic analysis on the impact of increased stent graft (SG) use for treatment of arteriovenous graft (AVG) anastomotic stenosis or arteriovenous fistula (AVF)/AVG in-stent restenosis (ISR) from United States point-of-care (POC) and Medicare perspectives. MATERIALS AND METHODS The analyses compared initial device and reintervention costs over 2 years between current and projected treatment mixes, including percutaneous transluminal angioplasty (PTA), bare metal stents (BMSs), and SGs. In projected scenarios, the absolute increase in SG use was approximately 3%. Costs included procedure reimbursement rates (Medicare) and device list prices (POC) for index procedures and reinterventions. Reintervention rates and types were informed by the RENOVA and RESCUE randomized trials. Reinterventions were primarily PTA only; however, stent use occurred a proportion of the time. BMS reintervention rates were assumed to be identical to PTA based on observational data. A population size of 1,000 patients was assumed. RESULTS To the POC (n = 1,000), increased SG use was predicted to result in cost savings ranging from $4,106 to $34,420 for AVG anastomotic stenosis. For AVF/AVG ISR, increased SG use was predicted to result in either a cost increase of $17,187 or a cost savings of $13,159. To Medicare (n = 1,000), increased SG use was predicted to save costs for both populations, with savings ranging from $57,401 to $169,544. CONCLUSIONS The use of SG for treatment of AVG anastomotic stenosis and AVF/AVG ISR appears to be economically favorable for POC providers and Medicare. Further data on reintervention rates are required from other SG trials to validate findings.
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Affiliation(s)
- Bart Dolmatch
- Department of Interventional Radiology, The Palo Alto Medical Foundation, Mountain View, California
| | - Andrew Hogan
- Cornerstone Research Group Inc., 3228 S Service Rd, Burlington, ON L7N 3H8, Canada
| | - Nicole Ferko
- Cornerstone Research Group Inc., 3228 S Service Rd, Burlington, ON L7N 3H8, Canada.
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Yang HT, Yu SY, Su TW, Kao TC, Hsieh HC, Ko PJ. A prospective randomized study of stent graft placement after balloon angioplasty versus balloon angioplasty alone for the treatment of hemodialysis patients with prosthetic graft outflow stenosis. J Vasc Surg 2018; 68:546-553. [PMID: 29622355 DOI: 10.1016/j.jvs.2017.12.062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 12/10/2017] [Indexed: 10/17/2022]
Abstract
BACKGROUND Hemodialysis graft outflow stenosis is a significant complication occurring in hemodialysis patients with prosthetic grafts for vascular access. Balloon angioplasty remains the first-line endovascular treatment of this complication, although covered stent graft implantation after balloon angioplasty also appears to be an effective and promising treatment. The aim of this study was to evaluate the efficacy and durability of stent graft placement after balloon angioplasty in comparison to balloon angioplasty alone for the treatment of graft outflow stenosis in hemodialysis patients. METHODS We conducted a prospective randomized study of 98 patients with clinically significant dialysis graft outflow stenosis treated in the vascular surgery section of a tertiary medical center. The patients were randomized into two groups; 49 patients were treated with stent graft placement after balloon angioplasty, and 49 patients were treated with balloon angioplasty alone. All patients underwent angiography of the graft site at 3 and 6 months after intervention, and restenosis rates were compared between the two groups. In addition, the duration of postintervention primary patency in the two groups was recorded and analyzed. RESULTS The postintervention restenosis rate of the stent graft placement group was superior to that seen in the balloon angioplasty alone group (9% vs 69% at 3 months [P < .0001] and 29% vs 72% at 6 months [P < .0001]). The mean postintervention primary patency duration was 380.22 ± 28.54 days for the stent graft placement group and 151.08 ± 16.79 days for the balloon angioplasty alone group (P < .0001). CONCLUSIONS The use of stent grafts in hemodialysis patients with graft outflow stenosis yielded superior results compared with the results seen in hemodialysis patients treated with balloon angioplasty alone. Patients treated with stent grafts after balloon angioplasty had a lower restenosis rate and a longer duration of postintervention primary patency. The placement of a stent graft after balloon angioplasty appears to be an optimal therapeutic approach for the treatment of hemodialysis patients with graft outflow stenosis.
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Affiliation(s)
- Hsuan-Tzu Yang
- Thoracic and Cardiovascular Department, Chang Gung Memorial Hospital, Tao Yuan City, Taiwan
| | - Sheng-Yueh Yu
- Thoracic and Cardiovascular Department, Chang Gung Memorial Hospital, Tao Yuan City, Taiwan
| | - Ta-Wei Su
- Thoracic and Cardiovascular Department, Chang Gung Memorial Hospital, Tao Yuan City, Taiwan
| | - Tsung-Chi Kao
- Thoracic and Cardiovascular Department, Chang Gung Memorial Hospital, Tao Yuan City, Taiwan
| | - Hung-Chang Hsieh
- Thoracic and Cardiovascular Department, Chang Gung Memorial Hospital, Tao Yuan City, Taiwan
| | - Po-Jen Ko
- Thoracic and Cardiovascular Department, Chang Gung Memorial Hospital, Tao Yuan City, Taiwan.
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Kitrou PM, Katsanos K, Papadimatos P, Spiliopoulos S, Karnabatidis D. A survival guide for endovascular declotting in dialysis access: procedures, devices, and a statistical analysis of 3,000 cases. Expert Rev Med Devices 2018; 15:283-291. [PMID: 29546804 DOI: 10.1080/17434440.2018.1454311] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Thrombosis is the most important access-related complication. Several declotting procedures have been suggested falling mainly into two categories; thrombolysis-dependent and thrombectomy-dependent. AREAS COVERED Seventeen studies after 2001 have been published on percutaneous treatment of thrombosed vascular access. Authors performed a systematic review of these studies together with a parametric meta-analysis of data available investigating clinical success, postintervention assisted primary patency (PAPP) and independent factors that could influence outcome measures. EXPERT COMMENTARY A shift to thrombectomy-dependent procedures is observed with a view to diminishing complications from the use of thrombolytic agents. Arteriovenous fistulas provide significantly better PAPP, while newer studies show improved, non-significant results compared with older ones. The role of improvement of devices for subsequent angioplasty is of equal importance, if not more, for improved declotting results.
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Affiliation(s)
- Panagiotis M Kitrou
- a Department of Interventional Radiology , Patras University Hospital, School of Medicine , Rion , Greece
| | - Konstantinos Katsanos
- a Department of Interventional Radiology , Patras University Hospital, School of Medicine , Rion , Greece
- b Department of Interventional Radiology , Guy's and St. Thomas' Hospitals, NHS Foundation Trust, King's Health Partners , London , UK
| | - Panagiotis Papadimatos
- a Department of Interventional Radiology , Patras University Hospital, School of Medicine , Rion , Greece
| | - Stavros Spiliopoulos
- c 2nd Department of Radiology , Interventional Radiology Unit, ATTIKO Athens University Hospital , Athens , Greece
| | - Dimitris Karnabatidis
- a Department of Interventional Radiology , Patras University Hospital, School of Medicine , Rion , Greece
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Chen MCY, Weng MJ, Liang HL. Endovascular bypass for salvage of vascular access in hemodialysis catheter-consigned patients. J Vasc Access 2018; 19:585-592. [PMID: 29560785 DOI: 10.1177/1129729818764132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE: This study was performed to retrospectively assess the efficacy of percutaneous creation of an intervascular bypass with or without stent graft deployment (endovascular bypass) for salvage of abandoned vascular access sites in hemodialysis catheter-consigned patients. METHODS: Salvage of abandoned vascular access sites was attempted in 16 patients with hemodialysis catheters. These vascular access sites were salvaged using endovascular bypass techniques to redirect the access flow to a nonarterialized vein as a new outflow conduit or cannulation segment. The postintervention primary, assisted primary, and secondary patency rates of the access site and bypass were calculated using the Kaplan-Meier method. RESULTS: The procedural and clinical success rates were both 100%. The postintervention primary patency rate of the bypass and access site at 360 days was 75.7 ± 12.5% and 56.8 ± 14.9%, respectively. The mean follow-up period was 461.9 days (range: 121-900 days). No major complications were observed. One bare bypass tunnel rupture and one pseudoaneurysm were noted during the procedure. CONCLUSION: Salvage of abandoned vascular access sites for hemodialysis catheter-consigned patients can be technically feasible and clinically successful using endovascular bypass techniques in selected patients when surgical revision is not considered or is not possible.
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Affiliation(s)
- Matt Chiung-Yu Chen
- 1 Department of Interventional Radiology, Yuan's General Hospital, Kaohsiung, Taiwan
| | - Mei-Jui Weng
- 2 Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Huei-Lung Liang
- 2 Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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Abstract
Stents are ubiquitously utilized in coronary and peripheral arterial disease. Interventional nephrologists, however, place stents in the venous outflow of the arteriovenous access. Stenosis is the predominant pathology that causes access dysfunction and will ultimately lead to thrombosis if uncorrected. Angioplasty and stent deployment are the current techniques available to combat stenosis. From initial bare metal stainless steel stents, the current generations of stents used are predominately covered nitinol stents. The latest randomized control trials reveal that stents decrease the number of interventions required to maintain patency but do not improve the overall access survival. Furthermore, bare metal stents have been shown to be inferior to stent grafts. This review discusses indications for stent deployment in the hemodialysis access, the current evidence for their use, and briefly touches on their complications.
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Affiliation(s)
- Kenneth Abreo
- School of Medicine, LSU Health Shreveport, Shreveport, LA, USA
| | - Adrian Sequeira
- School of Medicine, LSU Health Shreveport, Shreveport, LA, USA
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Hu H, Wu Z, Zhao J, Wang J, Huang B, Yang Y, Xiong F. Stent graft placement versus angioplasty for hemodialysis access failure: a meta-analysis. J Surg Res 2018; 226:82-88. [PMID: 29661293 DOI: 10.1016/j.jss.2018.01.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 11/26/2017] [Accepted: 01/17/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Hemodialysis is a common treatment for end-stage renal disease, and maintenance of access patency remains a key issue. Angioplasty is recommended as the first choice for access stenosis, but it poses a risk of a high rate of restenosis. Stent graft placement can generate a high patency rate of dialysis access. This study aimed to compare the primary patency of the treatment area and access circuit between stent grafts and angioplasty in dialysis access failure. MATERIALS AND METHODS Three electronic databases, namely, PubMed, Cochrane Library of Systematic Reviews, and EMBASE, were searched from the database inception to September 2017 without language restriction. Randomized controlled trials comparing the primary patency of the treatment area and access circuit between stent graft and angioplasty were included. Two independent reviewers assessed the quality of the trials and extracted relevant data. RESULTS Four trials satisfied our inclusion criteria. Our pooled results suggested that stent graft placement was associated with significantly higher primary patency of treatment area (hazard ratio: 0.65, 95% confidence interval: 0.55-0.77, P < 0.0001, I2 = 0) and access circuit (hazard ratio: 0.76, 95% confidence interval: 0.65-0.88, P = 0.0004, I2 = 0) in hemodialysis access compared with those of standard angioplasty. CONCLUSIONS The patency of hemodialysis access may be higher after stent graft placement combined with standard angioplasty than after angioplasty alone.
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Affiliation(s)
- Huanrui Hu
- West China Medical School of Sichuan University, West China Hospital, Chengdu, Sichuan Province, China
| | - Zhoupeng Wu
- Department of Vascular Surgery, West China Hospital of Sichuan University, West China Hospital, Chengdu, Sichuan Province, China
| | - Jichun Zhao
- Department of Vascular Surgery, West China Hospital of Sichuan University, West China Hospital, Chengdu, Sichuan Province, China.
| | - Jiarong Wang
- West China Medical School of Sichuan University, West China Hospital, Chengdu, Sichuan Province, China
| | - Bin Huang
- Department of Vascular Surgery, West China Hospital of Sichuan University, West China Hospital, Chengdu, Sichuan Province, China
| | - Yi Yang
- Department of Vascular Surgery, West China Hospital of Sichuan University, West China Hospital, Chengdu, Sichuan Province, China
| | - Fei Xiong
- Department of Vascular Surgery, West China Hospital of Sichuan University, West China Hospital, Chengdu, Sichuan Province, China
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Kitrou PM, Papadimatos P, Spiliopoulos S, Christeas N, Katsanos K, Karnabatidis D. Lysis-Assisted Balloon (LAB) Thrombectomy. A Declotting Technique for the Treatment of Thrombosed Arteriovenous Dialysis Grafts. 5-Year Experience of 241 Endovascular Procedures. Cardiovasc Intervent Radiol 2018; 41:245-252. [PMID: 29075875 DOI: 10.1007/s00270-017-1813-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 10/09/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND This is a retrospective single-center analysis investigating the results of a percutaneous lysis-assisted balloon (LAB) thrombectomy procedure for the treatment of thrombosed arteriovenous dialysis grafts (AVGs). MATERIALS AND METHODS Within 5 years (January 2012-December 2016), 291 declotting procedures were performed for the treatment of thrombosed dialysis arteriovenous fistulas or grafts. Data were available for 129 patients (75 men, 58.1%) with an AVG, undergoing 241 procedures [1.87 procedures/patient (1-10)]. Procedure includes initial lysis with 5 mg recombinant tissue plasminogen activator followed by thrombectomy with a high-pressure balloon for thrombus maceration using "facing sheaths" technique. 61 patients had ≥ 2 declotting procedures. In 80 cases (80/241; 33.2%), a stent graft (SG) was used for treatment of persistent stenosis. Main primary outcome measures were clinical success and postintervention assisted primary patency (PAPP). Secondary outcome measures included procedural complications and investigation of independent factors that could influence circuit survival. RESULTS Median PAPP was 434 days according to Kaplan-Meier survival analysis. Clinical success was 96.26%. In six cases (6/241, 2.49%) declotting failed and a catheter was placed. There were 16 minor (16/241, 6.64%) and no major complications. There was no significant difference in circuit survival regardless of SG use (No SG 406 days vs. SG 349 days; p = 0.24). There was a significant difference in favor of the second declotting compared to the first in 61 patients (first: 162 days vs. second: 447 days; p < 0.0001). CONCLUSION LAB thrombectomy resulted in high-circuit survival rates with increased technical success and minimum complications without the use of thrombectomy devices.
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Affiliation(s)
- Panagiotis M Kitrou
- Interventional Radiology Department, Patras University Hospital, Patras, Greece.
| | | | - Stavros Spiliopoulos
- 2nd Department of Radiology, Interventional Radiology Division, Attikon University Hospital, Athens, Greece
| | - Nicolaos Christeas
- Interventional Radiology Department, Patras University Hospital, Patras, Greece
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Kouvelos GN, Spanos K, Antoniou GA, Vassilopoulos I, Karathanos C, Matsagkas MI, Giannoukas AD. Balloon Angioplasty Versus Stenting for the Treatment of Failing Arteriovenous Grafts: A Meta-Analysis. Eur J Vasc Endovasc Surg 2017; 55:249-256. [PMID: 29258706 DOI: 10.1016/j.ejvs.2017.11.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 11/12/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess the outcomes of plain balloon angioplasty versus stenting for the treatment of failed or malfunctioning chronic haemodialysis arteriovenous grafts (AVGs). METHODS A systematic search of the literature was undertaken using the PUBMED, EMBASE, and Cochrane databases from January 2000 to September 2016 for articles comparing balloon angioplasty versus stenting in the management of failed or malfunctioning chronic haemodialysis AVGs. Results are reported as OR and 95% CI. RESULTS The search identified eight studies (1051 patients). Balloon angioplasty alone was used in 521 patients (49.6%) and stenting in 530 patients (50.4%). At the time of the endovascular re-intervention, the mean life of AVGs was 807.7±115.4 days for the balloon angioplasty and 714.2±96.3 days for the stenting group (p=.92). All AVGs were located in the arm. Most procedures (98.1%) were performed across the venous anastomosis, while 88% of the patients in the stenting group received a stent graft. The technical success rate was significantly higher in the stenting group (OR 0.16, 95% CI 0.08-0.31, p<.001). At 12 months, loss of primary and secondary patency was significantly higher in patients undergoing plain balloon angioplasty compared with stenting (OR 3.54, 95% CI 2.18-5.74, p<.001, and OR 1.82, 95% 1.17-2.82, p=.008, respectively). CONCLUSION Stenting is associated with better technical success and patency rates compared with plain angioplasty in treating failed or malfunctioning chronic haemodialysis AVGs, and thus it should be considered as the first line therapeutic option.
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Affiliation(s)
- George N Kouvelos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
| | - Konstantinos Spanos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George A Antoniou
- Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, UK
| | - Ioannis Vassilopoulos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Christos Karathanos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Miltiadis I Matsagkas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios D Giannoukas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Corti R, Quaretti P, Galli F, Moramarco LP, Cionfoli N, Leati G, Corbetta R, Tozzi M. New therapeutic options provided by off-label deployment of stent graft for tailored arteriovenous access salvage: Two cases. SAGE Open Med Case Rep 2017; 5:2050313X17741827. [PMID: 29163957 PMCID: PMC5692143 DOI: 10.1177/2050313x17741827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 10/17/2017] [Indexed: 11/20/2022] Open
Abstract
A tailored therapy to patient requirements by combining endovascular and surgical steps can be necessary to prolong the life of a vascular access. Stent grafts play a growing role for the therapy of dialytic access complications. Randomized multi-center trials, however, support the on-label use of stent grafts in the treatment of graft venous outflow and in-stent restenosis. The main contraindication to their use is an ongoing infection. We report two cases of new off-label application of Viabahn (Gore, flagstaff, USA) stent graft. In the first case, the failure of a radiocephalic early cannulation graft was treated by stent graft placement on the arterial inflow anastomosis, when emergent angiographic examination revealed the previously unknown high takeoff of the radial artery from the axillary artery. At 13-month follow-up, the target lesion remained untreated. In the second case, elbow stent graft occlusion with extended thrombosis occurred in a right radiocephalic fistula after 3 years of unassisted patency. Being the last option for vascular access, successful endovascular recanalization was carried out. After 3 months, however, the clinical setting relapsed. A two-stage hybrid strategy with vascular surgeon was arranged due to ongoing signs of local infection. Flow was restored by emergent thromboaspiration associated with a new stent graft placement as a endovascular bridge to subsequent surgical treatment. After 2 days, the overlapped stent grafts were excised as planned. Surgical rerouting was completed by polytetrafluoroethylene prosthetic bridge implantation across the elbow. At 4 months, the follow-up remained uneventful. In selected instances, the off-label use of stent grafts may expand the therapeutic options of the vascular access team.
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Affiliation(s)
- Riccardo Corti
- Unit of Interventional Radiology, Department of Radiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Pietro Quaretti
- Unit of Interventional Radiology, Department of Radiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Franco Galli
- Nephrology and Dialysis, IRCCS Fondazione Salvatore Maugeri, Pavia, Italy
| | - Lorenzo Paolo Moramarco
- Unit of Interventional Radiology, Department of Radiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Nicola Cionfoli
- Unit of Interventional Radiology, Department of Radiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giovanni Leati
- Unit of Interventional Radiology, Department of Radiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Riccardo Corbetta
- Vascular Surgery Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Matteo Tozzi
- Vascular Surgery Department, Center For Research on Organ Transplantation, University of Insubria, Varese, Italy
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Jones RG, Willis AP, Tullett K, Riley PL. Results of Stent Graft Placement to Treat Cephalic Arch Stenosis in Hemodialysis Patients with Dysfunctional Brachiocephalic Arteriovenous Fistulas. J Vasc Interv Radiol 2017; 28:1417-1421. [PMID: 28789817 DOI: 10.1016/j.jvir.2017.06.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 06/12/2017] [Accepted: 06/16/2017] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To determine effectiveness of the VIABAHN (W.L. Gore & Associates, Flagstaff, Arizona) stent graft to treat cephalic arch stenosis in patients with dysfunctional brachiocephalic arteriovenous fistulas after inadequate venoplasty response. MATERIALS AND METHODS Between 2012 and 2015, patients with failed venoplasty of symptomatic cephalic arch stenosis received a VIABAHN stent graft. Follow-up venography was performed at approximately 3, 6, and 12 months. Data were retrospectively analyzed with patency estimated using Kaplan-Meier and log-rank methodology. There were 39 patients included. RESULTS Technical and clinical success was 100%. Primary target lesion patency was 85% (95% confidence interval [CI], 69%-93%), 67% (95% CI, 50%-80%), and 42% (95% CI, 25%-57%) at 3, 6, and 12 months. There was no significant difference in patency with regard to sex or age (P = .8 and P = .6, respectively). Primary assisted patency was 95% (95% CI, 82%-99%) at 3, 6, and 12 months. Access circuit primary patency was 85% (95% CI, 69%-93%), 67% (95% CI, 50%-80%), and 42% (95% CI, 25%-57%) at 3, 6, and 12 months. There was no significant difference in patency between patients with the stent graft as the first treatment episode in the cephalic arch and those that had previous intervention at this site (P = .98). There were 48 repeat venoplasty procedures performed in the cephalic arch to maintain patency, including 7 repeat VIABAHN insertions. No complications were encountered. CONCLUSIONS The VIABAHN stent graft is a safe, effective, and durable device for treating cephalic arch stenosis when venoplasty fails.
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Affiliation(s)
- Robert G Jones
- Department of Interventional Radiology, Queen Elizabeth Hospital Birmingham, University Hospital, Edgbaston, Birmingham B152WB, United Kingdom.
| | - Andrew P Willis
- Department of Interventional Radiology, Queen Elizabeth Hospital Birmingham, University Hospital, Edgbaston, Birmingham B152WB, United Kingdom
| | - Karen Tullett
- Department of Renal Services, Queen Elizabeth Hospital Birmingham, University Hospital, Edgbaston, Birmingham B152WB, United Kingdom
| | - Peter L Riley
- Department of Interventional Radiology, Queen Elizabeth Hospital Birmingham, University Hospital, Edgbaston, Birmingham B152WB, United Kingdom
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50
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Stent grafts for treatment of cannulation zone stenosis and arteriovenous graft venous anastomosis. J Vasc Access 2017; 18:47-52. [DOI: 10.5301/jva.5000680] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2016] [Indexed: 11/20/2022] Open
Abstract
Stent grafts (SGs) are widely used for treatment of failing vascular accesses, fistulas and grafts. The mechanical barrier of the covered stent prevents in-stent stenosis and can be used to effectively correct ruptured vein and aneurysms. Treatment of cannulation zone stenosis with SG can be justified when its use is obligatory, in order to prevent total access loss. Although there are worrying complications attendant on SG insertion and cannulation, including jeopardizing future access creation, most studies report no complications of SG in cannulation zone stenosis. SGs for treatment of arteriovenous graft venous anastomosis stenosis is controversial. Two large randomized trials conclusively demonstrate improved primary patency with SGs at the venous anastomosis of arteriovenous graft at up to two years when compared with percutaneous transluminal angioplasty, sustained for up to 2 years and reducing the number of interventions per patient year. However, the ultimate goal of SG treatment of venous anastomosis stenosis is preventing thrombosis and increasing graft longevity, which was unfortunately not fully achieved.
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