Stent tunnel technique to save thrombosed native hemodialysis fistula with extensive venous aneurysm

Interwoven nitinol stent-assisted arteriovenous fistula maturation: 2 year-outcomes of a single center experience

OBJECTIVES

The aim of this study was to report 2-year outcomes of interwoven nitinol (SuperaTM) stent-assisted arteriovenous fistula (AVF) maturation in patients who presented with non-matured AVF.

METHODS

We reviewed the clinical data of 20 patients who presented with non-matured AVF (19 patients with brachiocephalic AVF and 1 patient with radiocephalic AVF) and underwent balloon angioplasty followed by SuperaTM stenting in the cephalic vein for long-term hemodialysis between January 2017 and January 2022. The outcomes were evaluated in these patients in terms of technical success, post-intervention complications, reintervention, and cumulative patency (6 months, 1 year, and 2 years).

RESULTS

The study included 20 patients who presented with non-matured AVF. The mean age of the patients was 65 years (range, 40-85). The SuperaTM stents of size 6.5 mm were used in 15 patients (75%), and those of 7.5 mm and 5.5 mm were used in 4 (20%) and 1 (5%) patient, respectively. The average stent length was 99.5 mm (range, 80-120). Technical success was achieved in all patients. Early use within 1 week by needling at the SuperaTM stent segment (cannulation zone) was successful in all patients without any complications. The mean follow-up time was 24.5 months. During the follow-up period, reinterventions to maintain the function of AVF were performed in 8 patients (40%) (7 patients with juxta-anastomotic stenosis, 1 patient with in-stent restenosis). The reintervention rate was 0.39 procedures per patient per year. The primary patency at 6 months, 1 year, and 2 years were 85.5%, 62.6%, and 54.2%, respectively. The assisted primary patency at 6 months, 1 year, and 2 years were 95%, 84.5%, and 78.8%, respectively.

CONCLUSIONS

The use of the SuperaTM stent to improve the AVF maturation rate was associated with acceptable outcomes at 2 years. Its benefit over other strategies was the early use of the access for hemodialysis.

Recanalization of thrombosed aneurysmal hemodialysis arterovenous fistulas using a hybrid technique based on data from a single center

Objective

To explore the technical specifications and clinical outcomes of thrombosed aneurysmal haemodialysis arteriovenous fistula (AVF) treated with ultrasound-guided percutaneous transluminal angioplasty combined with minimal aneurysmotomy.

Methods

This case series study included 11 patients who had thrombosed aneurysmal AVF and underwent salvage procedures over a 13-month period. All procedures were performed under duplex guidance. Minimal aneurysmotomy was performed, along with manual thrombectomy and thrombolytic agent infusion, followed by angioplasty to macerate the thrombus and sufficiently dilate potential stenoses. A successful procedure was defined as immediate restoration of flow through the AVF.

Results

The 11 patients (four males and seven females) had a mean age of 49.6 years ± 11.9 years. Six patients (54.5%) had two or more aneurysms. The mean aneurysm maximal diameter was 21.5 mm (standard deviation: ± 5.0 mm), and the mean thrombus length was 12.9 cm (8–22 cm). Ten (83.3%) of the 12 procedures were technically successful. The mean duration of operation was 150.9 minutes (standard deviation: ± 34.2 minutes), and mean postoperative AVF blood flow was 728.6 ml/min (standard deviation: ± 53.7 mi/min). The resumption of hemodialysis was successful in all 11 cases, with a clinical success rate of 100%. The primary patency rates were 90.0% and 75.0% at three and four months over a mean follow-up time of 6.3 months (3–12 months). The secondary patency rates were 90.4% at three and four months.

Conclusion

A hybrid approach combining ultrasound-guided percutaneous transluminal angioplasty and minimal aneurysmotomy might be a safe and effective method for thrombosed aneurysmal AVF salvage.

Arteriovenous access in hemodialysis: A multidisciplinary perspective for future solutions

In hemodialysis, vascular access is a key issue. The preferred access is an arteriovenous fistula on the non-dominant lower arm. If the natural vessels are insufficient for such access, the insertion of a synthetic vascular graft between artery and vein is an option to construct an arteriovenous shunt for punctures. In emergency situations and especially in elderly with narrow and atherosclerotic vessels, a cuffed double-lumen catheter is placed in a larger vein for chronic use. The latter option constitutes a greater risk for infections while arteriovenous fistula and arteriovenous shunt can fail due to stenosis, thrombosis, or infections. This review will recapitulate the vast and interdisciplinary scenario that characterizes hemodialysis vascular access creation and function, since adequate access management must be based on knowledge of the state of the art and on future perspectives. We also discuss recent developments to improve arteriovenous fistula creation and patency, the blood compatibility of arteriovenous shunt, needs to avoid infections, and potential development of tissue engineering applications in hemodialysis vascular access. The ultimate goal is to spread more knowledge in a critical area of medicine that is importantly affecting medical costs of renal replacement therapies and patients’ quality of life.