Stent and Stent-Graft Use in Arteriovenous Dialysis Access

Use of a Paclitaxel Drug-Eluting Stent for the Treatment of Hemodialysis Access Outflow Stenosis

PURPOSE

To evaluate the outcomes and durability of drug-eluting stents (DESs) for the treatment of hemodialysis access outflow stenosis.

MATERIAL AND METHODS

A single-center retrospective analysis was conducted of all patients with hemodialysis vascular access outflow stenosis treated with a paclitaxel-coated DES (Eluvia; Boston Scientific, Marlborough, Massachusetts) between January 2020 and July 2022. A total of 34 DESs were implanted to treat outflow stenosis in 32 patients. Primary target lesion patency after stent deployment was the main outcome. Comparison between the time interval free from target lesion reintervention (TLR) after previous plain balloon angioplasty (PBA) and that after stent deployment for the same target lesion was considered a secondary outcome.

RESULTS

The primary patency at 6, 12, and 18 months was 63.1%, 47.6%, and 41.7%, respectively. The secondary patency rate was 100% at 18 months. The median time interval free from TLR increased from 4.1 to 11.9 months (P < .001). No adverse events were observed during the median follow-up period of 387 days.

CONCLUSIONS

The patency rates after use of DES for hemodialysis access outflow stenosis were comparable with results for drug-coated balloons and stent grafts, addressing recoil and minimizing the risk of jailing by a covered stent.

Endovascular tools for vascular access stenosis: Flow-chart proposal

Stenosis represents the most relevant arteriovenous fistula (AVF) pathology and can affects the entire conduit forming the fistula, from afferent artery to central venous vessels. Correction of vascular access stenosis significantly affects the survival and quality of life for end stage renal disease patients (ESRD) dependent on hemodialysis. Guidelines consider the procedure of percutaneous transluminal angioplasty (PTA) relevant for the primary treatment of these lesions with excellent results in restoring AVF immediately at the end of the procedure. From first AVF angioplasty in 1981 to now, wide scientific innovation has led to development of new devices, composed by different materials and technologies, specific for the site and the type of stenosis to be treated, able to manage resistant stenotic lesion and to reduce stenosis recurrences. International guidelines do not clearly specify all treatment possibilities in the individual case. In this review the authors want to provide specific information on most used devices for stenosis treatment based on literature evidence, showing when and where to use the various tools available with flow-chart treatment proposal.

Cephalic arch restenosis rates in hemodialysis patients with brachiocephalic fistulae: a retrospective multicenter analysis of 3301 patients

Background

We evaluated restenosis rates at the cephalic arch after percutaneous angioplasty and stenting procedures in patients with brachial artery to cephalic vein arteriovenous fistula (BCAVF) hemodialysis access.

Methods

We used data from adult hemodialysis patients treated at a national network of 44 outpatient interventional facilities during Oct 2011–2015. We included data from patients with BCAVF who received an exclusive angioplasty, or stent with angioplasty, for treatment of cephalic arch stenosis and had ≥1 subsequent evaluation of the cephalic arch. Median percent restenosis per month at cephalic arch and days between encounters was calculated from the 1st index to 2nd procedure, and for up to 4 subsequent encounters. Analyses were stratified by intervention and device types.

Results

We identified a cohort of 3301 patients (mean age 62.2 ± 13.9 years, 58.5% male, 33.2% white race) with a BCAVF who had an angioplasty, or stent, at the cephalic arch for an index and ≥ 1 follow-up procedure. Between the 1st index to 2nd procedure, patients who received an angioplasty (n = 2663) or stent (n = 933) showed a median decrease of 18.9 and 16.5% in luminal diameter per month and a median time of 93 and 91 days between encounters, respectively. Restenosis and day rates were similar for standard versus high-pressure angioplasties. Bare metal stents showed 10.1 percentage point higher restenosis rate compared to stent grafts. Restenosis rates and time to restenosis were relatively consistent across subsequent encounters.

Conclusions

Findings suggest hemodialysis patients with a BCAVF who require an angioplasty or stent to treat a stenosis at the cephalic arch will have stenosis reformed at a rate of 18.9 and 16.5% per month after the first intervention, respectively. Findings suggest patients are at risk of having significant lesions at the cephalic arch within 3 months after the previous intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02728-4.

Delayed cephalic arch rupture following balloon angioplasty

Background

Vascular access care comes with its substantial cost that include but not limited to poor blood flow during dialysis, stenosis throughout the dialysis circuits, aneurysmal dilatation, clots formation and complete thrombosis. Acute cephalic arch rupture is not that uncommon but delayed rupture is rare presentation that was not discussed previously.

Case presentation

We describe a case of a 70-year-old female with end-stage renal disease (ESRD) undergoing a fistulogram and angioplasty of cephalic arch stenosis that resulted in a small vessel rupture that was successfully treated with prolonged balloon inflation initially. Unfortunately, this was complicated with massive venous rupture after initiating hemodialysis. The diseased segment was successfully treated with covered stent placement. This paper review and discuss cephalic arch stenosis, clinical presentation, and available initial and bailout treatment strategies.

Conclusions

Primary management of cephalic arch rupture is a prolong-low pressure balloon angioplasty, with covered stent across the site of extravasation if persisted. This case depicted a delayed vascular rupture following hemodialysis in patient with previously controlled extravasation that necessities covered stent placement. No data in the literature suggested the time that is required to avoid dialysis and improve healing.

Efficacy and safety of secondary procedures for maintaining arteriovenous hemodialysis access patency: protocol for a systematic review and network meta-analysis

BACKGROUND

Arteriovenous (AV) hemodialysis access creation is recommended by international guidelines as the preferred method of hemodialysis access. However, most AV access sites will require revision to maintain patency. Although several treatment options exist, many have not been directly compared. We intend to compare the relative effectiveness of methods to maintain post-intervention primary patency of failing AV access.

METHODS

We will search EMBASE, MEDLINE, CENTRAL, trial registries, the grey literature, and ancestry and citation search from January 1977 to present, for randomized controlled trials comparing interventions to maintain primary patency of AV access. Two investigators will independently and blindly review all identified citations and extract data from included studies. The primary outcome is the primary patency 6 months after intervention. Secondary outcomes include immediate technical and functional success, reinterventions, patency, and mortality. Risk of bias, subgroup analyses, and sensitivity analyses are planned.

DISCUSSION

There are a number of treatment modalities for the management of failing AV access. However, most modalities have only been directly compared with plain old balloon angioplasty, and currently synthesized evidence focuses on individual pairwise comparisons. In light of the lack of comprehensively synthesized evidence and clinical equipoise, our study intends to synthesize currently available evidence though it is unclear which treatment modality is most effective.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID CRD42020148224.

Effect of carvedilol on arteriovenous graft primary patency

BACKGROUND

The major mechanisms of arteriovenous graft (AVG) failure due to intimal hyperplasia (IH) are smooth muscle cell proliferation and inflammation. Therefore, carvedilol may improve AVG primary patency because of its anti-proliferative and anti-inflammatory activities.

METHODS

The data of end-stage renal disease patients receiving regular hemodialysis were collected from the National Health Insurance Research database. The end point was the first percutaneous transluminal angioplasty (PTA) for AVG failure or death during a follow-up period of two years or the end of 2013. The analysis was calculated with Cox proportional hazard model.

RESULTS

There were 3028 patients treated with carvedilol and 13,704 patients not treated with carvedilol. According to a univariate analysis, the carvedilol group was younger, received more anti-hypertensive medications and platelet aggregation inhibitors, and had higher rates of diabetes mellitus and hyperlipidemia but had lower rates of hypotension and smoking. According to a multivariate analysis, after controlling for covariates, the use of carvedilol for more than 84 days reduced the probability of a first PTA for AVG failure by 9% compared with no use of carvedilol (p = 0.021), but the use of carvedilol for 1 to 84 days did not.

CONCLUSION

The results of this study indicate that the use of carvedilol for more than 84 days improves the primary patency of AVGs, but the use of carvedilol for less than 84 days does not.

Outcomes of the Gore Excluder abdominal aortic aneurysm leg endoprosthesis for treatment of central vein stenosis or occlusion in patients with chronic hemodialysis

OBJECTIVE

Central venous occlusive disease is a critical complication in long-term hemodialysis patients with arteriovenous (AV) dialysis circuits. The purpose of this retrospective, single-arm cohort study was to evaluate the effectiveness of an abdominal aortic aneurysm (AAA) contralateral leg endoprosthesis to treat symptomatic central venous occlusive diseases in patients with chronic hemodialysis.

METHODS

A prospective cohort study included 60 patients on hemodialysis presenting with central venous stenosis or occlusion, who were treated with a Gore Excluder AAA contralateral leg stent graft between December 2013 and July 2018. Follow-up angiography was obtained at 3, 6, and 12 months. The outcomes and duration of primary circuit and target site patency were measured from the time of the stent graft implantation to the first reintervention for AV circuit dysfunction and target site restenosis. Secondary patency was calculated from stent graft implantation to the point when AV access was no longer attainable.

RESULTS

Circuit primary patency rate was 54.9% at 1 year of Gore Excluder AAA contralateral leg or iliac extender stent grafts, implanted in 60 hemodialysis patients with central vein occlusive disease. Cumulative target site primary patency rate was 88.3% at 1 year. Secondary patency rate was 95% during follow-up. Patients with concomitant lesions had a significantly higher risk of circuit primary patency dysfunction.

CONCLUSIONS

Treatment of central vein obstructions in hemodialysis patients with stent grafts has been appealing owing to the tapered shape with a larger diameter and the availability of various lengths.

Use of Paclitaxel Eluting Stents in Arteriovenous Fistulas: A Pilot Study

Purpose

We report short-term patency outcomes of a proof of concept study conducted to determine the efficacy of drug-eluting stent (DES) for the treatment of arteriovenous fistula (AVF) stenosis in hemodialysis patients.

Materials and Methods

This is a single-center, retrospective observational study involving 10 patients with AVF dysfunction treated with DESs between January 2017 and December 2017. The primary outcome was AVF patency confirmed by sonographic and clinical assessment at 1 month and 6 to 9 months after treatment.

Results

A total of 12 DESs were deployed in 10 patients with dysfunctional AVF (radiocephalic: 7, brachiocephalic: 3). During the early follow up (mean: 28.6 days), primary access circuit and DES patency was 100%, with an average volume flow rate of 886.4 mL/min. Nine patients were available for short-term follow up (mean: 202.4 days; 1 unrelated death), with a mean volume flow rate of 1,048.9 mL/min. The primary DES patency was 7/9 (77.8%), and 3 patients required angioplasty at other parts of the circuit (primary access circuit patency: 4/9 [44.4%]). The assisted primary access circuit patency was 77.8%. In 2 patients, the ultrasound revealed that the DESs were thrombosed without any antecedent stenosis; they were salvaged with angioplasty. Both patients previously underwent 2 DESs implanted and recently stopped dual antiplatelet therapy. B-mode sonographic assessment at all timepoints showed minimal intimal ingrowth on the stent struts.

Conclusion

This study demonstrates acceptable short-term patency for DESs in the treatment of AVF stenosis. Dual antiplatelet therapy is probably mandatory in the short term.

Central venous disease in hemodialysis patients

Central venous disease (CVD) is difficult to treat and often resistant to treatment. In CVD, hemodialysis vascular access should sometimes be abandoned, or in serious cases, the patient's life may be threatened. Therefore, prevention is ideal. However, as the prevalence of chronic kidney disease (CKD) has increased steadily with population aging, CKD patients with a peripherally inserted central catheter (PICC) are encountered frequently. PICCs can cause CVD, and the basilic vein, which is regarded as the important last option for native arteriovenous fistula (AVF) creation in end-stage renal disease (ESRD) patients, is destroyed frequently after its use as the entry site of PICC. The most well-established risk factors for CVD are a history of central venous catheter (CVC) insertion and its duration of use. Therefore, to reduce the incidence of CVD, catheterization in the central vein (CV) should be minimized, along with its duration of use. In this review, we will first explain the basic territories of the CV and introduce its pathophysiology, clinical features, and advanced treatment options. Finally, we will emphasize prevention of CVD.

Treatment of failing arterio-venous dialysis graft by angioplasty, stent, and stent graft: Two-years analysis of patency rates and cost-effectiveness

The objective of this prospective randomized single-center study was to compare primary and secondary patency rates, number of percutaneous transluminal angioplasty (PTA) interventions and cost-effectiveness among PTA, deployment of a stent, or a stent graft in the treatment of failing arteriovenous dialysis grafts (AVG) due to restenosis in the venous anastomosis or the outflow vein. Altogether 60 patients with failing AVG and restenosis in the venous anastomosis or the outflow vein were randomly assigned to either PTA, placement of a stent (E-Luminexx^®) or stent graft (Fluency Plus^®). After the procedure, patients with stent or stent graft received dual antiplatelet therapy for the next three months. Follow-up angiography was scheduled at 3, 6, and 12 months unless requested earlier due to suspected stenosis or malfunction of the access. Subsequently, angiography was performed only if requested by the clinician. During a median follow-up of 22.4 (IQR=5.7) months patients with PTA, stent, or stent graft required 3.1±1.7, 2.5±1.7, or 1.7±2.1 (P=0.031) secondary PTA interventions. The primary patency rates were 0, 18 and 65% at 12 months and 0, 18 and 37% at 24 months in the PTA, stent, and stent graft group respectively (P<0.0001). The cost of the procedures in the first two years was €7,900±€3,300 in the PTA group, €8,500±€4,500 in the stent group, and €7,500±€6,200 in the stent graft group (P=0.45). We conclude that the treatment of failing dialysis vascular access by the deployment of a stent graft significantly improves its primary patency rates and decreases the number of secondary PTA interventions; however, the reduction in costs for maintaining AVG patency is not significant.

Long-term outcomes of bovine pericardial patch angioplasty for recurrent stenosis in vascular access: A UK single-centre experience

INTRODUCTION:

Stenosis of an arteriovenous fistula or arteriovenous graft for dialysis is a common problem. Stenosis may lead to a number of problems including failure of the fistula. Treatment of stenosis is commonly with percutaneous angioplasty or surgical patch angioplasty with autologous vein or synthetic graft or patch. Here we report the use of bovine pericardial patch angioplasty as an alternative mode of patch angioplasty when percutaneous intervention has failed.

METHODS:

Patients with fistulae treated with bovine patch angioplasty between 2013 and 2016 were identified from a prospectively maintained renal access database (Cyberren^®). Patient records were reviewed, noting type and location of access, patency, re-interventions and complications post bovine pericardial patch.

RESULTS:

A total of 40 patients were identified as having undergone bovine pericardial patch angioplasty between January 2013 and April 2016. The median time from fistula formation to bovine pericardial patch was 15 months (interquartile range (IQR): 5-43). Median duration of follow-up was 14 months (IQR: 5-18). Primary patency at 6, 12, 18 and 24 months was 91%, 66%, 61% and 54%, respectively. Secondary patency was 94%, 91%, 80% and 77% at the same time points, respectively. In total, 15 patients required 23 re-interventions post bovine pericardial patch. There has been no report of infection or aneurysm formation.

CONCLUSION:

Bovine pericardial patch angioplasty for recurrent stenosis in arteriovenous fistulae for dialysis access provides a robust alternative to other surgical patches with the added advantage of allowing early needling and relative resistance to infection. Rates of restenosis and failure post bovine pericardial patch are low.