Transjugular Venous Approach for Endovascular Interventions in Hemodialysis Grafts and Fistulas of the Upper Extremities

Transjugular approach: comparison with conventional endovascular treatment of native arteriovenous fistulas

OBJECTIVES

The aim of this study was to compare the outcomes of the transjugular approach with those of the conventional approach for endovascular treatment of arteriovenous fistulas (AVFs).

METHODS

Between May 2015 and July 2019, 112 patients with endovascular treatment of dysfunctional or immature AVFs were included and divided into the transjugular (n = 46) and conventional (n = 66) groups. Electronic medical records and angiography of the patients were retrospectively reviewed to assess technical and clinical success rates, time to first fistulography, total procedure time, primary and secondary patency, and complications in both groups.

RESULTS

There were no significant differences in technical success rate (87.0% vs 97.0%; P = .062), clinical success rate (80.4% vs 90.9%; P = .109), or total procedure time (60.2 vs 57.9 min; P = .670) between the groups. Cox proportional hazards models showed that the cumulative primary patency was significantly higher in the transjugular group than in the conventional group (P = .041; 6-month patency rates, 93.8% vs 91.5%). Also, a statistically significant difference was found between the cumulative secondary patency of the groups (P = .014; 6-month patency rates, 91.4% vs 86.5%). No major complications were observed.

CONCLUSIONS

Transjugular endovascular treatment of AVFs was successful and effective. Longer patency periods were observed when treated via transjugular access.

ADVANCES IN KNOWLEDGE

This article compared the outcomes of transjugular approaches with those of conventional approaches in the endovascular treatment of native AVFs and showed higher patency periods/rates in the transjugular group than in the conventional group.

The Retrograde Basilic Approach for Balloon-Assisted Maturation of Brachiocephalic Arteriovenous Fistulas

PURPOSE

To assess the feasibility and outcomes of an approach utilizing transbasilic access for balloon-assisted maturation (BAM) of brachiocephalic arteriovenous fistulas (BCAVF).

MATERIALS AND METHODS

This retrospective analysis comprised 28 patients (mean age 63 years ± 10.8) who underwent endovascular treatment of their immature BCAVFs via a basilic approach from December 2016 to December 2018. The mean age of the BCAVF was 3.3 months ± 1.4 at time of BAM. Other demographic data, vascular access characteristics, procedural data, technical and clinical success rates and adverse events were also evaluated.

RESULTS

All patients had inflow juxta-anastomotic stenoses, with 4 patients (14%) having concomitant outflow tract stenoses, and 1 patient (4%) having a short segment occlusion at the stenotic juxta-anastomotic segment. Technical success was achieved in 27 patients (96%). The mean diameter of the largest balloon used was 5.7mm ± 0.6. Clinical success was achieved in 22 patients (79%), with 6 patients (21%) requiring a subsequent additional intervention before successful cannulation. No perioperative adverse events were observed.

CONCLUSION

The retrograde basilic approach is feasible, safe and effective for balloon-assisted maturation of BCAVFs.

Efficacy of the transjugular approach in endovascular intervention for hemodialysis access comparing with conventional approach

PURPOSE

Compared with the conventional approach, the benefits of the transjugular approach in endovascular intervention for hemodialysis access avoids complications due to direct puncture and reduces direct radiation exposure to the hands of operator. The aim of this non-inferiority study was to evaluate the efficacy of the transjugular approach in endovascular intervention for hemodialysis access comparing with conventional approach.

METHODS

We retrospectively assessed endovascular intervention for hemodialysis access performed in our hospital from 2012 to 2016, divided into the conventional approach group and the transjugular approach group. The hemodialysis access survival rate, re-intervention survival rate, and lesion characteristics were comparatively evaluated.

RESULTS

We included 223 cases in 118 patients (146 cases with conventional approaches and 77 cases with transjugular approaches). There was a higher incidence of thrombosis with the conventional approach (p < 0.001), however, no significant difference in the hemodialysis access type or main lesion location. The transjugular approach showed either a better hemodialysis access survival rate (p = 0.017) and a trend toward improved re-intervention survival rate (p = 0.098) than the conventional approach. Following classification according to the presence of thrombus, there was no significant difference in either the hemodialysis access survival rate or the re-intervention survival rate between the approaches with or without thrombus.

CONCLUSION

The transjugular approach could be performed in most cases and was similar to the conventional approach in terms of outcomes. The transjugular approach should be considered as an alternative to either replace or use in combination with the conventional approach in endovascular intervention for hemodialysis access.

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.

Transfemoral Venous Access Facilitates Upper Extremity Dialysis Interventions: Procedural Success and Clinical Outcomes

PURPOSE

To report technical success and clinical outcomes of transfemoral venous access for upper extremity dialysis interventions.

MATERIALS AND METHODS

A total of 15 patients underwent a transfemoral venous approach for fistulography (n = 4; 27%) or thrombectomy (n = 11; 73%) over a 14-month period. Access characteristics, sheath size, thrombectomy method, angioplasty site, fluoroscopy time, radiation dose, technical and clinical success, complications, and post-intervention primary and secondary patency rates were recorded.

RESULTS

Access type included arteriovenous fistulas (n = 10; 67%) and grafts (n = 5; 33%). The most common configuration was brachio-brachial (n = 6; 38%). Mean age of access was 37 months. Mean prior interventions were 4. Right CFV access was used in all patients using 6-8-French (most common: 7-French [n = 10; 67%]) sheaths. Most thrombectomies (n = 11; 73%) required both pharmacologic and mechanical maceration (n = 9; 82%). All accesses required angioplasty to treat underlying stenosis at the outflow vein (n = 12; 80%) or arteriovenous anastomosis (n = 9; 90%). Mean fluoroscopy time was 26.43 min. Air kerma and dose area product were 178.06 ± 225.77 mGy and 57,768.83 ± 87,553.29 μGym², respectively. Procedural and clinical success rates were 93% and 80%, respectively. Technical failure was due to persistent stenosis in one patient. Clinical failure was due to unsuccessful dialysis immediately following intervention in three patients. Mean post-intervention primary patency and secondary patency durations were 2.8 and 4.8 months, respectively. Primary patency rates at 1 and 3 months were 50% and 35%, respectively. Secondary patency rates at 1 and 3 months were 58% and 30%, respectively.

CONCLUSION

A transfemoral venous approach for intervention of upper extremity dialysis accesses may be a valuable adjunct to traditional approaches.

Transjugular percutaneous endovascular treatment of dysfunctional hemodialysis access

PURPOSE

To evaluate the feasibility and the outcomes of transjugular percutaneous endovascular treatment of dysfunctional hemodialysis access in patients with chronic kidney disease.

METHODS

A total of 50 transjugular treatments in 38 patients with arteriovenous fistulas or arteriovenous grafts from September 2011 to May 2015 were included in this study. Medical records and angiographies were retrospectively reviewed. Success rate, patency rate, procedure time, and complications including internal jugular vein stenosis were evaluated.

RESULTS

A total of 50 sessions of transjugular treatments were performed in 38 patients. There were 31 native arteriovenous fistulas including 10 immature cases and 19 arteriovenous grafts. Among the 50 cases, technical success was achieved in 45 and clinical success was achieved in 44; 37 cases (74%) with multiple stenotic sites were treated by the transjugular approach without placement of cross-sheaths. The mean time from puncture of the internal jugular vein to first fistulography was 10 min, and the mean total procedure time was 64 min. The primary patency rate at 6 months was 77%, while the secondary patency rate at 6 months was 97%. Perforation occurred in two cases during conventional percutaneous transluminal angioplasty after failure of the transjugular approach. One dissection occurred during the transjugular approach. There was no newly developed internal jugular vein stenosis during a mean follow-up period of 19.3 months.

CONCLUSION

For the treatment of dysfunctional or immature hemodialysis access, the transjugular approach is a feasible and effective option that avoids injury to the graft or draining vein, especially in immature fistulas.