Sharp Needle Recanalization for Salvaging Hemodialysis Accesses with Chronically Occluded Peripheral Outflow

Sharp needle reconstructs peripheral outflow for patients with malfunctional arteriovenous fistula

OBJECTIVE

To investigate the feasibility and efficacy of combining ultrasound-guided sharp needle technique with percutaneous transluminal angioplasty (PTA) for treating outflow stenosis or dysfunction in arteriovenous fistula (AVF) among hemodialysis patients.

METHODS

From October 2021 to March 2023, patients with occluded or malfunctional fistula veins not amenable to regularly angioplasty were retrospectively enrolled in the study. They underwent ultrasound-guided sharp needle intervention followed by PTA. Data on the location and length between the two veins, technical success, clinical outcomes, and complications were collected. Patency rates post-angioplasty were calculated through Kaplan-Meier analysis.

RESULTS

A total of 23 patients were included. The mean length of the reconstructed extraluminal segment was 3.18 cm. The sharp needle opening was performed on the basilic vein (60.9%), brachial vein (26.1%), or upper arm cephalic vein (13%) to create outflow channels. Postoperatively, all cases presented with mild subcutaneous hematomas around the tunneling site and minor diffuse bleeding. The immediate patency rate for the internal fistulas was 100%, with 3-month, 6-month, and 12-month patency rates at 91.3%, 78.3%, and 43.5%, respectively.

CONCLUSION

Sharp needle technology merged with PTA presents an effective and secure minimally invasive method for reconstructing the outflow tract, offering a new solution for recanalizing high-pressure or occluded fistulas.

Percutaneous Endovascular Creation of a Neo-arteriovenous Fistula in Dysfunctional Hemodialysis Fistulas

PURPOSE

Arteriovenous fistulas (AVF) is the preferred type of hemodialysis access, but when an arteriovenous anastomosis (AVA) calcifies, surgical revision of the AVF may be required. We report a technique to create percutaneous artery-to-vein intervascular neo-fistulas for re-anastomosis of AVA and evaluate its safety and efficacy.

MATERIALS AND METHODS

9 patients who failed either guidewire navigation or conventional balloon dilation for calcified AVA stenosis/occlusion underwent a salvage procedure of their dialysis shunt by the percutaneous creation of a new arteriovenous fistula. Needle puncture of the adjacent supplying artery and outflow vein under ultrasonographic and/or fluoroscopic guidance was performed and followed by balloon dilation, with or without stent graft placement. The detailed techniques, technical success, primary neo-fistula patency, primary and secondary access patency rates were reported herein.

RESULTS

Technical success was achieved in 100% of the 9 patients treated (7 neo-fistulas with stents and 2 neo-fistulas without stent placement). The median primary neo-fistula and access patencies were 15 and 5 months, respectively. The primary neo-fistula patency rates at 6, 12, and 18 months were 72.9%, 54.7% and 27.9%, respectively, with secondary neo-fistula and access patency rates of 72.9%, 72.9% and 72.9%, respectively. One delayed complication of pseudoaneurysm formation occurred, which was managed by the successful endovascular deployment of a stent graft on an out-patient basis.

CONCLUSION

Percutaneous artery-to-vein intervascular neo-fistula creation is feasible for re-anastomosing calcified AVA, with low adverse effects and acceptable primary neo-fistula and secondary access patency.

A systematic review of right atrial bypass grafting in the management of central venous occlusive disease in patients undergoing hemodialysis

INTRODUCTION

Central venous occlusive disease (CVOD) is a complication that can occur in patients with end-stage renal disease who are receiving hemodialysis. When CVOD develops, patients often require multiple re-interventions to maintain their dialysis access. CVOD can be treated by various strategies such as balloon angioplasty, stenting, lower limb or extra-anatomical grafts, hybrid grafts or surgical bypasses such as right atrial (RA). In this systematic review, we aim to evaluate the indications, technical aspects, and outcomes after RA bypass grafting for the treatment of CVOD in hemodialysis patients.

METHODS

A systematic and comprehensive literature search was conducted using various electronic databases. We included articles that reported described and reported outcomes of RA bypass grafting for the treatment of CVOD in hemodialysis patients. A narrative review of the indications and technical aspects of RA bypass grafting was performed. We also pooled and reported the primary patency, secondary patency, postoperative complications, and 30-day mortality of RA bypass grafting.

RESULTS

A total of 21 studies with 55 patients who underwent RA bypass grafting were included in our systematic review. Follow-up period ranged from 0.5 to 84 months. The mean pooled primary patency and secondary patency of RA bypass grafting were 8.1 ± 4.9 and 21.7 ± 20.1 months, respectively. The incidence of early postoperative complications such as surgical site infection, bleeding, and access thrombosis was 0%, 4%, and 4%, respectively. The overall 30-day mortality was 4%.

CONCLUSIONS

This systematic review summarizes the patient characteristics, technical features and outcomes of RA bypass grafting in the treatment of hemodialysis-related CVOD. RA bypass grafting may be a viable last-resort option when less invasive or conventional treatment options have been exhausted.

The outcome of sharp recanalization of chronic central venous occlusions in patients undergoing hemodialysis

BACKGROUND

Patients on hemodialysis are particularly vulnerable to central venous occlusion (CVO). Endovascular treatment has gained wide acceptance for the treatment of CVO. However, difficulties in crossing the occluded segment can be encountered during conventional endovascular management. Sharp recanalization has been adopted when conventional endovascular methods could not recanalize the obstructed region. This study aimed to assess the outcome of the sharp venous recanalization technique with angioplasty and stenting in the treatment of CVO in Egyptian patients undergoing hemodialysis.

METHODS

This retrospective study is based on data from a prospectively maintained department database of patients under regular hemodialysis who underwent the sharp venous recanalization technique for CVO. Routinely, the patients were followed up at 3, 6, and 12 months with a clinical examination. The primary outcomes were technical success and primary patency. Secondary outcomes included complication rates and clinical success.

RESULTS

This study included 40 patients. Thirty-six patients (90%) achieved technical and clinical success. Seven patients (17.5%) had immediate postoperative complications. Four cases had minor complications (10%) and three patients had major complications (7.5%): hemothorax in two patients (5.1%) and pneumothorax in one patient (2.6%). At the 1-year follow-up, reintervention was required in nine patients (22.5%), with primary patency rate of 77.5% and a secondary patency rate of 100%.

CONCLUSIONS

Sharp recanalization offers a solution for patients undergoing hemodialysis who developed CVO and failed to be recanalized using the conventional endovascular method. It offered promising technical success, clinical improvement, and good primary patency rates.

Outcome and Risk Factors of Restenosis Post Percutaneous Transluminal Angioplasty at Juxta-Anastomotic of Wrist Autogenous Radial-Cephalic Arteriovenous Fistulas: A Retrospective Cohort Study

BACKGROUND

This retrospective cohort study was to determine the factors related to restenosis post percutaneous transluminal angioplasty (PTA) at juxta-anastomotic of wrist radial-cephalic arteriovenous fistulas (RC-AVFs).

METHODS

We conducted a retrospective study of patients who underwent their first PTA for juxta-anastomotic stenosis at RC-AVF from January 1, 2016, to December 31, 2020. Patient and stenotic lesion characteristics and PTA procedure factors were included in the analysis. The primary and assisted primary patency post PTA of RC-AVFs were evaluated using the Kaplan-Meier analysis and log-rank test. A Cox proportional hazard model was used to identify factors associated with restenosis post PTA. The receiver operating characteristic (ROC) curve was employed to evaluate the predictive value of the risk factors for restenosis post PTA.

RESULTS

A total of 65 patients with a mean age of 59.09 ± 14.94 years were enrolled in the study. The mean RC-AVF age was 9.2 (4.9, 35.05) months, and the median time of intervention for stenosis was 10.8 (4.05, 41.35) months after AVF creation. The primary patency rates following the first PTA at 3, 6, 12, and 24 months were 93.9, 84.6, 63.1, and 55.4%, respectively. The assisted primary patency rates at 3, 6, 12, and 24 months were 95.4, 90.8, 87.7, and 84.6%, respectively. Cox proportional hazard regression analysis revealed the maximum balloon diameter >5 mm had a lower postoperative restenosis rate compared with the maximum balloon diameter ≤5 mm (hazard ratio = 0.422; 95% confidence interval [CI]: 0.201-0.884; P = 0.022). ROC curve analysis showed that the area under the curve of the maximum balloon diameter during PTA was 0.624 (95% CI, 0.486-0.762). The best critical value for the maximum balloon diameter was 6 mm, the sensitivity was 64.5%, and the specificity was 61.8%.

CONCLUSIONS

For the first PTA at juxta-anastomotic of wrist RC-AVFs without thrombosis and complete occlusion, the use of a balloon with a maximum diameter of ≤5 mm is a risk factor to the occurrence of restenosis within 12 months post PTA. The result may help in tailoring surveillance programs in patients with RC-AVF stenosis.

Management of Central Venous Stenosis and Occlusion in Dialysis Patients

Central venous occlusions (CVOs) of the major intrathoracic veins (jugular, subclavian, brachiocephalic, superior vena cava) can cause debilitating symptoms, negatively impact arteriovenous fistula/graft function, or limit potential access creation options in end-stage kidney disease (ESKD) utilizing hemodialysis (HD). This review summarizes the incidence, pathophysiology, indications/contraindications, and management options of CVOs in the ESKD on HD population and concludes with considerations and examples when planning endovascular central recanalization procedures, which have risen as the first-line management when appropriate.

Sharp recanalization for treatment of central venous occlusive disease in hemodialysis patients

BACKGROUND

The purpose of the present study was to evaluate the technical feasibility and safety of sharp recanalization for central venous occlusive disease (CVOD) in patients requiring hemodialysis.

METHODS

Patients with CVOD requiring hemodialysis who had undergone endovascular recanalization using sharp devices, including the stiff end of a guidewire, Chiba needle, or RUS-100 to cross occluded segments after conventional techniques had failed were included. The needle was guided toward a target placed at the opposite end of the occlusion. Although the guidewire was passed though the occlusion, subsequent procedures such as percutaneous transluminal angioplasty could be performed.

RESULTS

A total of 27 sharp recanalization procedures in 25 patients were performed. Two attempts failed, 1 patient had undergone two separate successful procedures, and 23 procedures in 23 patients were successful. The overall technique success was 92.6%. The stiff end of a guidewire was the first choice for all the procedures, and recanalization was achieved in 18 patients (66.7%). A Chiba biopsy needle was used in six procedures (22.2%), with 100% technical success. A RUPS-100 set was used in two procedures (7.4%), with one aborted because of concern for complications. The occlusion was subsequently crossed using a Chiba needle. Four minor adverse events (two of mediastinal hematoma and two of chest pain) had occurred, and two major adverse events (pericardial tamponade and acute pleural effusion in one patient [4%], treated with the guidewire stiff-end technique, who recovered after drainage) had occurred.

CONCLUSIONS

Sharp recanalization is safe and feasible with high technical success for CVOD in patients requiring hemodialysis who cannot be recanalized using conventional techniques.

Sharp Needle Recanalization Technique for Peripheral Hemodialysis Arteriovenous Fistula Occlusion

PURPOSE

To determine the efficacy of a percutaneous sharp needle recanalization technique for the treatment of peripheral hemodialysis arteriovenous fistula (AVF) occlusion.

MATERIALS AND METHODS

This study included 13 patients (14 procedures) between May 2010 and February 2020 with non-thrombotic AVF occlusion wherein guidewire passage through the occluded segment had failed. We successfully passed the guidewire through the occluded segment using a sharp needle recanalization technique with Chiba or Colapinto needles, under ultrasound or fluoroscopic guidance. The type of AVF, site and length of occlusion, technical success, complications, and long-term patency were analyzed.

RESULTS

Technical success was achieved in 12 (85.7%) out of 14 procedures. The procedure failed in two patients due to the poor angle of approach in the axillary area and diffuse severe stenosis in the draining cephalic vein. In eight procedures, sharp needle recanalization was performed under ultrasound guidance, while the other six procedures were performed under fluoroscopic guidance. Chiba and Colapinto needles were used in five and nine procedures, respectively. The mean length of occlusion was 2.7 cm (range 1.8-4.2 cm). There was one case of mild complication, that is, mild contrast extravasation, which was treated by stent deployment. The post-intervention primary patency rates at 6 months, 1 year, and 2 years were 81.8%, 36.4%, and 18.2%, respectively.

CONCLUSION

The results of this limited series suggest that the sharp needle recanalization technique is a simple and effective method for the treatment of peripheral non-thrombotic AVF occlusion.

A Fine Needle Recanalization Technique for Iliac Artery Occlusions in Endovascular Surgery

BACKGROUND

Endovascular intervention for chronic total occlusions (CTOs) in aortoiliac occlusive disease (AIOD) poses technical challenges. In this manuscript, our experience of fine needle recanalization for the treatment of iliac artery CTO is described.

METHOD

A prospective database recorded treatment of 11 limbs in 11 patients since 2011 using this technique. The majority of these CTO were of the common iliac artery (n = 9).

RESULTS

Technical success rate was 91% (n = 10). One failed case was due to tortuous iliac anatomy. There was no restenosis of the treated segments at 8 weeks and no major complications, perforations, major limb loss, or periprocedural mortality.

CONCLUSIONS

This technique is a safe and viable adjunct for difficult CTO in AIOD with suitable anatomy. It benefits from being a simple, low-profile, low-cost coaxial system and should be part of the armamentarium with other advanced endovascular techniques.

Endovascular bypass for salvage of vascular access in hemodialysis catheter-consigned patients

PURPOSE:

This study was performed to retrospectively assess the efficacy of percutaneous creation of an intervascular bypass with or without stent graft deployment (endovascular bypass) for salvage of abandoned vascular access sites in hemodialysis catheter-consigned patients.

METHODS:

Salvage of abandoned vascular access sites was attempted in 16 patients with hemodialysis catheters. These vascular access sites were salvaged using endovascular bypass techniques to redirect the access flow to a nonarterialized vein as a new outflow conduit or cannulation segment. The postintervention primary, assisted primary, and secondary patency rates of the access site and bypass were calculated using the Kaplan-Meier method.

RESULTS:

The procedural and clinical success rates were both 100%. The postintervention primary patency rate of the bypass and access site at 360 days was 75.7 ± 12.5% and 56.8 ± 14.9%, respectively. The mean follow-up period was 461.9 days (range: 121-900 days). No major complications were observed. One bare bypass tunnel rupture and one pseudoaneurysm were noted during the procedure.

CONCLUSION:

Salvage of abandoned vascular access sites for hemodialysis catheter-consigned patients can be technically feasible and clinically successful using endovascular bypass techniques in selected patients when surgical revision is not considered or is not possible.

The Pipeline Technique: A Simple Endovascular Technique for Creation of a Jump Graft Bypass

Purpose

The purpose of this study is to describe a technique by which a bypass was created percutaneously with two overlapping covered stents for salvage of a thrombotic right brachial-axillary arteriovenous graft without recanalizable outflow.

Methods and results

With the pipeline technique, a 16 cm bypass tract covered with two overlapping Viabahn stents between the hemodialysis graft and the right subclavian vein was created as an alternative access outflow. The hemodialysis graft was successfully salvaged without complications and functioned well for more than 6 months except for one thrombosis which occurred 147 days after its salvage.

Conclusions

We describe an endovascular bypass technique using a sheath-dilator set and two angiographic catheters to salvage a thrombotic hemodialysis graft.