Ultrasound-Guided Pharmacomechanical Thrombolysis and Angioplasty for Treatment of Acute Thrombotic Prosthetic Arteriovenous Access: 5-Year Experience with 154 Procedures in a Single Center

Ultrasound guided percutaneous sharp recanalization for restoring patency from peripheral chronic total occlusions of hemodialysis accesses

OBJECTIVE

Resistant chronic total occlusion (CTO) lesions present an ongoing challenge for conventional endovascular interventions to restore functional hemodialysis (HD) access. This study endeavors to present a novel endovascular approach utilizing ultrasound (USG)-guided percutaneous sharp recanalization to cross the resistant occlusions and evaluates its effectiveness.

METHODS

This is a multi-center retrospective review of consecutive patients received USG guided sharp recanalization for the treatment of resistant CTO lesions of their HD access between 1st January 2019 and 31st July 2023. Data encompassing patient demographics, access and lesion characteristics, procedural specifics, associated complications, immediate clinical outcomes, and outcomes during follow-up were collected. The procedural technical and clinical success, Kaplan-Meier estimated target lesion (TLPP), access circuit primary patency (ACPP), and index access secondary patency (SP) were reported.

RESULTS

During the study period, 22 patients underwent USG-guided sharp recanalization procedures in the three participating centers with median follow-up of 14.5 months. Both the technical and clinical success were 100%. Only two patients experienced minor complications of localized hematoma over the access, with no instances of major complication. Kaplan-Meier estimated TLPP and ACPP at 3-, 6-, and 12 months were 90.9%, 68.2%, 56.8%, and 90.9%, 63.6%, 52.1% respectively. The SP rates were 100%, 95.5%, and 84.1% at 3-, 6-, and 12 months respectively.

CONCLUSION

USG guided percutaneous sharp recanalization is an effective and safe endovascular approach to treat resistant CTO lesions of dysfunctional HD access.

Assessment of Sonographic Parameters for Predicting Primary Patency Rate in Hemodialysis Patients With Venous Valve-Related Stenosis

OBJECTIVES

Ultrasonography is more frequently used in patients with arteriovenous fistula (AVF) stenosis. The aim of this study is to use sonographic parameters for predicting primary patency in hemodialysis patients with venous valve-related stenosis (VVRS) who are treated by ultrasound-guided percutaneous transluminal angioplasty (PTA).

METHODS

A total of 229 VVRS patients who underwent PTA between January 2017 and December 2021 were enrolled. Clinical characteristics were retrospectively collected. Sonographic parameters were measured both before and after PTA. Univariate and multivariate Cox analyses were performed to identify independent factors associated with primary patency rate.

RESULTS

All measured sonographic parameters improved after PTA compared to before PTA. Before PTA, the diameter of VVRS > 1.0 mm, age ≤ 57 years, and body mass index (BMI) > 21.57 kg/m2 were associated with better outcomes. While the diameter of radial artery, proximal radial artery close to the anastomosis, brachial artery, the flow volume of brachial artery, the length and peak velocity (PV) of the VVRS, and the diameter and PV after the VVRS had no association with the primary patency rate. After PTA, only patients with a diameter of VVRS > 4.0 mm had favorable outcome. In addition, patients with a gain of diameter of VVRS > 2.4 mm after PTA had a trend of better outcomes.

CONCLUSIONS

The diameter of VVRS before and after PTA could be served as markers to predict primary patency rate and second patency rate in AVF patients with VVRS. The gain of diameter of VVRS could also be a potential marker.

CLINICAL IMPACT

Using simple markers of sonographic parameters, we could quickly identify patients with a higher risk of restenosis. These patients should be followed more closely in case of restenosis at early. It is also beneficial to the prevention of thrombosis. These measures help to preserve more valuable vascular for a long-term dialysis. Additionally, the physician should pay more attention on the dialysis-related complications in these risky patients, such as hemodialysis-related hypotension.

Ultrasound-guided nitinol stent implantation to treat early restenosis of arteriovenous fistula: A 69-case study with 1-year outcome

BACKGROUND

To investigate the feasibility, methods and effects of interventional ultrasound in nitinol stent implantation to treat early restenosis after percutaneous transluminal angioplasty (PTA) in autogenous arteriovenous fistula (AVF).

METHODS

From April 2018 to December 2021, 69 patients with early restenosis of AVF received ultrasound-guided nitinol stent implantation (UNSI) and were followed-up. Imaging features of the stent and procedure by ultrasound were observed. The technical success rate, clinical success rate and incidence of complications were recorded and counted. Target lesion primary patency (TLPP), access circuit primary patency (ACPP) and access circuit secondary patency (ACSP) were estimated.

RESULTS

Ultrasonography can show the structure of the stent and guide the stenting process clearly. Both the technical and clinical success rates were 100%. Thirty-one patients had in-stent restenosis (ISR), which was treated by plain balloon (PB) PTA or drug coated balloon (DCB) PTA. The TLPP at 3, 6, 12 and 24 months were 100.0%, 94.2%, 63.4% and 39.6%, respectively. The ACPP at 3, 6, 12 and 24 months were 98.6%, 91.6%, 60.2% and 35.2%, respectively. The ACSP at 3, 6, 12 and 24 months were 98.6%, 98.6%, 95.6% and 93.8%, respectively. The TLPP of ISR after DCB PTA at 3, 6 and 12 months were 100.0%, 100.0% and 93.6%, respectively.

CONCLUSIONS

This pilot study indicates ultrasonography can accurately guide nitinol stent implantation in AVF and this technique is a feasible and minimally invasive treatment for early restenosis after PTA with good short- and medium-term patency. DCB PTA may be used to deal with the ISR and is a way to prolong the patency of nitinol stent.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Effects of Arteriovenous Thrombolysis Combined with Mechanical Thrombectomy on Efficacy and Neurological Function of Acute Cerebral Infarct Patients

Objective

To investigate the effects of arteriovenous thrombolysis combined with mechanical thrombectomy on clinical efficacy, neurological function, and the changes of nerve injury markers of acute cerebral infarct (ACI) patients.

Methods

A total of 143 cases with ACI admitted to our hospital from June 2017 to June 2019 were elected as research subjects. Among them, 69 cases of patients who received treatment of arteriovenous thrombolysis were considered as group A, and 74 cases of patients who received treatment of arteriovenous thrombolysis combined with mechanical thrombectomy were considered as group B. NIHSS score, clinical efficacy, vascular recanalization, adverse reactions, hemodynamics, neurological injury indexes, duration of coma, length of hospital stay, and prognosis of patients in the two groups were compared.

Results

After treatment, the NIHSS score of group A was higher than that of group B (P < 0.05), the clinical efficacy of group B was better than that of group A, and the incidence of adverse reactions was lower than that of group A (P < 0.05). There was no difference in vascular recanalization rate, duration of coma, and prognosis between the two groups (P > 0.05). Length of hospital stay, maximum peak velocity after treatment (Vs), and mean flow rate (Vm) of group A were lower than those of group B, while vascular resistance index (RI), pulsatility index (PI), serum glutamic acid (Glu), neuron-specific enolase (NES), and S100β protein detected by enzyme-linked immunosorbent assay (ELISA) of group A were higher than those of group B (P < 0.05).

Conclusion

Arteriovenous thrombolysis combined with mechanical thrombectomy has a significant effect on ACI, with high safety and quick effect. In addition, it has a stronger effect on improving and protecting the neurological function of patients, which is worth promoting in clinical practice.

Comparison between endovascular versus hybrid thrombectomy for arteriovenous graft under complete ultrasound guidance

BACKGROUND

Endovascular treatment of acute thrombosed arteriovenous grafts performed completely under ultrasound guidance has rarely been reported. We compared the efficacy of a new endovascular thrombectomy technique (percutaneous manual thromboaspiration through the introducer sheath) with classical hybrid thrombectomy (minimally invasive surgical thrombectomy combined with high-pressure angioplasty) performed completely under ultrasound guidance, for arteriovenous graft thrombosis.

METHODS

This was a retrospective cohort study involving patients receiving hemodialysis who underwent arteriovenous graft thrombectomy between January 2014 and December 2017. We divided 130 participants into an intervention (endovascular) group (N.=65) and a control (classical hybrid) group (N.=65) according to the thrombectomy technique. The procedural success rate, immediate outcomes and patency were compared between the groups.

RESULTS

There was no significant difference in the procedural success rate (92.31% vs. 89.23%, P=0.55) between the intervention and control groups, respectively. No major complications were noted, but two cases of vessel rupture occurred in the control group and three cases of vessel rupture occurred in the intervention group. The procedure time in the intervention group was significantly shorter than that in the control group (74±14.21 min vs. 109.05±19.20 min, respectively; P<0.05). During the 6-month follow-up, we found no significant difference in the postintervention primary patency rate (48.33% vs. 55.17%; P=0.51) or the postintervention second patency rate (83.33% vs. 84.49%; P=0.79) between the intervention and control groups, respectively. Dialysis clearance and ≥50% stenosis were predictors of postintervention primary patency (hazard ratio, 7.80; 95% confidence interval: 1.75-34.81; P=0.01; and hazard ratio, 6.43; 95% confidence interval: 2.43-17.03; P<0.001), respectively.

CONCLUSIONS

Completely ultrasound-guided percutaneous manual thromboaspiration through the introducer sheath can be used for thrombosed arteriovenous grafts. This approach has the advantage of shorter operative time compared with hybrid treatment.