Treatment of hemodialysis vascular access rupture irresponsive to prolonged balloon tamponade: retrospective evaluation of the effectiveness of N-butyl cyanoacrylate seal-off technique

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.

Use of the Viabahn covered stent for the treatment of venous rupture during interventions of dysfunctional or thrombosed hemodialysis vascular access

BACKGROUND

Angioplasty-related vessel rupture is a common complication of interventions. The effect of covered stents to treat venous rupture has been evaluated in smaller series, but should be further evaluated.

OBJECTIVE

To report the immediate outcomes and patency rates of a covered stent to rescue angioplasty-related venous rupture of hemodialysis vascular access.

METHODS

From January 2013 to December 2018, 113 procedures complicated with vessel ruptures were retrospectively analyzed from a prospectively collected database of 8146 hemodialysis access interventions. The strategies to salvage vessel ruptures were based on the discretion of the treating physicians. Follow-up outcomes were obtained via review of the angiographic images, procedural notes, and medical and dialysis records within 12 months after the index procedures.

RESULTS

A total of 52 vessel ruptures (21 fistulas, 31 grafts) salvaged by using Viabahn covered stents were enrolled. Vessel ruptures developed in 28 (53.8%) thrombectomy procedures. Device success was achieved in all procedures (100%) and clinical success was achieved in 50 (96.2%). The primary patency of the stent area was 66.0% at 6 months and 50.0% at 12 months. The primary patency of the entire access circuit was 27.4% at 6 months and 16.0% at 12 months. The most common cause of access circuit primary patency loss was thrombotic occlusion for graft accesses and restenosis at stent area for native accesses. Eleven vascular accesses were abandoned within 12 months after vessel ruptures, and the secondary patency rate of the entire access circuit was 78.0% at 12 months.

CONCLUSIONS

Treatment of angioplasty-induced vessel rupture of hemodialysis vascular accesses by using Viabahn covered stents has good immediate outcomes and patency results at the stent area. Nonetheless, the patency rate of entire access circuit was still below the threshold recommended by guidelines.