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Bai H, Varsanik MA, Thaxton C, Ohashi Y, Gonzalez L, Zhang W, Aoyagi Y, Kano M, Yatsula B, Li Z, Pocivavsek L, Dardik A. Disturbed flow in the juxta-anastomotic area of an arteriovenous fistula correlates with endothelial loss, acute thrombus formation, and neointimal hyperplasia. Am J Physiol Heart Circ Physiol 2024; 326:H1446-H1461. [PMID: 38578237 DOI: 10.1152/ajpheart.00054.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 02/27/2024] [Accepted: 03/28/2024] [Indexed: 04/06/2024]
Abstract
Clinical failure of arteriovenous neointimal hyperplasia (NIH) fistulae (AVF) is frequently due to juxta-anastomotic NIH (JANIH). Although the mouse AVF model recapitulates human AVF maturation, previous studies focused on the outflow vein distal to the anastomosis. We hypothesized that the juxta-anastomotic area (JAA) has increased NIH compared with the outflow vein. AVF was created in C57BL/6 mice without or with chronic kidney disease (CKD). Temporal and spatial changes of the JAA were examined using histology and immunofluorescence. Computational techniques were used to model the AVF. RNA-seq and bioinformatic analyses were performed to compare the JAA with the outflow vein. The jugular vein to carotid artery AVF model was created in Wistar rats. The neointima in the JAA shows increased volume compared with the outflow vein. Computational modeling shows an increased volume of disturbed flow at the JAA compared with the outflow vein. Endothelial cells are immediately lost from the wall contralateral to the fistula exit, followed by thrombus formation and JANIH. Gene Ontology (GO) enrichment analysis of the 1,862 differentially expressed genes (DEG) between the JANIH and the outflow vein identified 525 overexpressed genes. The rat jugular vein to carotid artery AVF showed changes similar to the mouse AVF. Disturbed flow through the JAA correlates with rapid endothelial cell loss, thrombus formation, and JANIH; late endothelialization of the JAA channel correlates with late AVF patency. Early thrombus formation in the JAA may influence the later development of JANIH.NEW & NOTEWORTHY Disturbed flow and focal endothelial cell loss in the juxta-anastomotic area of the mouse AVF colocalizes with acute thrombus formation followed by late neointimal hyperplasia. Differential flow patterns between the juxta-anastomotic area and the outflow vein correlate with differential expression of genes regulating coagulation, proliferation, collagen metabolism, and the immune response. The rat jugular vein to carotid artery AVF model shows changes similar to the mouse AVF model.
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MESH Headings
- Animals
- Neointima
- Hyperplasia
- Arteriovenous Shunt, Surgical
- Thrombosis/physiopathology
- Thrombosis/pathology
- Thrombosis/genetics
- Thrombosis/etiology
- Thrombosis/metabolism
- Mice, Inbred C57BL
- Rats, Wistar
- Male
- Jugular Veins/metabolism
- Jugular Veins/pathology
- Jugular Veins/physiopathology
- Disease Models, Animal
- Carotid Arteries/pathology
- Carotid Arteries/physiopathology
- Carotid Arteries/metabolism
- Carotid Arteries/surgery
- Mice
- Rats
- Regional Blood Flow
- Endothelium, Vascular/metabolism
- Endothelium, Vascular/physiopathology
- Endothelium, Vascular/pathology
- Renal Insufficiency, Chronic/pathology
- Renal Insufficiency, Chronic/physiopathology
- Renal Insufficiency, Chronic/genetics
- Renal Insufficiency, Chronic/metabolism
- Endothelial Cells/metabolism
- Endothelial Cells/pathology
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Affiliation(s)
- Hualong Bai
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, Connecticut, United States
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, United States
| | - M Alyssa Varsanik
- Section of Vascular Surgery, Department of Surgery, University of Chicago Medicine, Chicago, Illinois, United States
| | - Carly Thaxton
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, Connecticut, United States
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, United States
| | - Yuichi Ohashi
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, Connecticut, United States
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, United States
| | - Luis Gonzalez
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, Connecticut, United States
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, United States
| | - Weichang Zhang
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, Connecticut, United States
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, United States
| | - Yukihiko Aoyagi
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, Connecticut, United States
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, United States
| | - Masaki Kano
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, Connecticut, United States
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, United States
| | - Bogdan Yatsula
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, Connecticut, United States
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, United States
| | - Zhuo Li
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, Connecticut, United States
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, United States
| | - Luka Pocivavsek
- Section of Vascular Surgery, Department of Surgery, University of Chicago Medicine, Chicago, Illinois, United States
| | - Alan Dardik
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, Connecticut, United States
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, United States
- Department of Cellular and Molecular Physiology, Yale University; New Haven, Connecticut, United States
- Department of Surgery, VA Connecticut Healthcare Systems, West Haven, Connecticut, United States
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2
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Applewhite B, Andreopoulos F, Vazquez-Padron RI. Periadventitial biomaterials to improve arteriovenous fistula and graft outcomes. J Vasc Access 2024; 25:713-727. [PMID: 36349745 DOI: 10.1177/11297298221135621] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
Periadventitial biomaterials have been employed for nearly three decades to promote adaptive venous remodeling following hemodialysis vascular access creation in preclinical models and clinical trials. These systems are predicated on the combination of scaffolds, hydrogels, and/or particles with therapeutics (small molecules, proteins, genes, and cells) to prevent venous stenosis and subsequent maturation failure. Periadventitial biomaterial therapies have evolved from simple drug delivery vehicles for traditional drugs to more thoughtful designs tailored to the pathophysiology of access failure. The emergence of tissue engineering strategies and gene therapies are another exciting new direction. Despite favorable results in experimental and preclinical studies, no periadventitial therapy has been clinically approved to improve vascular access outcomes. After conducting an exhaustive review of the literature, we identify the seminal studies and clinical trials that utilize periadventitial biomaterials and discuss the key features of each biomaterial format and their respective shortcomings as they pertain to access maturation. This review provides a foundation from which clinicians, surgeons, biologists, and engineers can refer to and will hopefully inspire thoughtful, translatable treatments to finally address access failure.
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Affiliation(s)
- Brandon Applewhite
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
- Department of Biomedical Engineering, University of Miami College of Engineering, Coral Gables, FL, USA
| | - Fotios Andreopoulos
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
- Department of Biomedical Engineering, University of Miami College of Engineering, Coral Gables, FL, USA
| | - Roberto I Vazquez-Padron
- Department of Biomedical Engineering, University of Miami College of Engineering, Coral Gables, FL, USA
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3
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He Y, Anderson B, Hu Q, Hayes RB, Huff K, Isaacson J, Warner KS, Hauser H, Greenberg M, Chandra V, Kauser K, Berceli SA. Photochemically Aided Arteriovenous Fistula Creation to Accelerate Fistula Maturation. Int J Mol Sci 2023; 24:ijms24087571. [PMID: 37108733 PMCID: PMC10142855 DOI: 10.3390/ijms24087571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/10/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023] Open
Abstract
Rates of arteriovenous fistula maturation failure are still high, especially when suboptimal size veins are used. During successful maturation, the vein undergoes lumen dilatation and medial thickening, adapting to the increased hemodynamic forces. The vascular extracellular matrix plays an important role in regulating these adaptive changes and may be a target for promoting fistula maturation. In this study, we tested whether a device-enabled photochemical treatment of the vein prior to fistula creation facilitates maturation. Sheep cephalic veins were treated using a balloon catheter coated by a photoactivatable molecule (10-8-10 Dimer) and carrying an internal light fiber. As a result of the photochemical reaction, new covalent bonds were created during light activation among oxidizable amino acids of the vein wall matrix proteins. The treated vein lumen diameter and media area became significantly larger than the contralateral control fistula vein at 1 week (p = 0.035 and p = 0.034, respectively). There was also a higher percentage of proliferating smooth muscle cells in the treated veins than in the control veins (p = 0.029), without noticeable intimal hyperplasia. To prepare for the clinical testing of this treatment, we performed balloon over-dilatation of isolated human veins and found that veins can tolerate up to 66% overstretch without notable histological damage.
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Affiliation(s)
- Yong He
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL 32611, USA
| | | | - Qiongyao Hu
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL 32611, USA
| | - R B Hayes
- Alucent Biomedical Inc., Salt Lake City, UT 84108, USA
| | - Kenji Huff
- Alucent Biomedical Inc., Salt Lake City, UT 84108, USA
| | - Jim Isaacson
- Alucent Biomedical Inc., Salt Lake City, UT 84108, USA
| | | | - Hank Hauser
- Alucent Biomedical Inc., Salt Lake City, UT 84108, USA
| | | | - Venita Chandra
- Division of Vascular Surgery, Department of Surgery, Stanford University, Stanford, CA 94305, USA
| | | | - Scott A Berceli
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Florida, Gainesville, FL 32611, USA
- North Florida/South Georgia Veterans Health System, Gainesville, FL 32608, USA
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4
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Applewhite B, Gupta A, Wei Y, Yang X, Martinez L, Rojas MG, Andreopoulos F, Vazquez-Padron RI. Periadventitial β-aminopropionitrile-loaded nanofibers reduce fibrosis and improve arteriovenous fistula remodeling in rats. Front Cardiovasc Med 2023; 10:1124106. [PMID: 36926045 PMCID: PMC10011136 DOI: 10.3389/fcvm.2023.1124106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/07/2023] [Indexed: 03/04/2023] Open
Abstract
Background Arteriovenous fistula (AVF) postoperative stenosis is a persistent healthcare problem for hemodialysis patients. We have previously demonstrated that fibrotic remodeling contributes to AVF non-maturation and lysyl oxidase (LOX) is upregulated in failed AVFs compared to matured. Herein, we developed a nanofiber scaffold for the periadventitial delivery of β-aminopropionitrile (BAPN) to determine whether unidirectional periadventitial LOX inhibition is a suitable strategy to promote adaptive AVF remodeling in a rat model of AVF remodeling. Methods Bilayer poly (lactic acid) ([PLA)-]- poly (lactic-co-glycolic acid) ([PLGA)] scaffolds were fabricated with using a two-step electrospinning process to confer directionality. BAPN-loaded and vehicle control scaffolds were wrapped around the venous limb of a rat femoral-epigastric AVF during surgery. AVF patency and lumen diameter were followed monitored using Doppler ultrasound surveillance and flow was measured before euthanasia. AVFs were harvested after 21 days for histomorphometry and immunohistochemistry. AVF compliance was measured using pressure myography. RNA from AVF veins was sequenced to analyze changes in gene expression due to LOX inhibition. Results Bilayer periadventitial nanofiber scaffolds extended BAPN release compared to the monolayer design (p < 0.005) and only released BAPN in one direction. Periadventitial LOX inhibition led to significant increases in AVF dilation and flow after 21 days. Histologically, BAPN trended toward increased lumen and significantly reduced fibrosis compared to control scaffolds (p < 0.01). Periadventitial BAPN reduced downregulated markers associated with myofibroblast differentiation including SMA, FSP-1, LOX, and TGF-β while increasing the contractile marker MYH11. RNA sequencing revealed differential expression of matrisome genes. Conclusion Periadventitial BAPN treatment reduces fibrosis and promotes AVF compliance. Interestingly, the inhibition of LOX leads to increased accumulation of contractile VSMC while reducing myofibroblast-like cells. Periadventitial LOX inhibition alters the matrisome to improve AVF vascular remodeling.
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Affiliation(s)
- Brandon Applewhite
- Department of Biomedical Engineering, University of Miami, Coral Gables, FL, United States
| | - Aavni Gupta
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Yuntao Wei
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Xiaofeng Yang
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
| | - Laisel Martinez
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Miguel G. Rojas
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Fotios Andreopoulos
- Department of Biomedical Engineering, University of Miami, Coral Gables, FL, United States
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
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5
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Chan JS, Wang Y, Cornea V, Roy-Chaudhury P, Campos B. Early Adventitial Activation and Proliferation in a Mouse Model of Arteriovenous Stenosis: Opportunities for Intervention. Int J Mol Sci 2021; 22:ijms222212285. [PMID: 34830167 PMCID: PMC8623099 DOI: 10.3390/ijms222212285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/07/2021] [Accepted: 11/10/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Arteriovenous fistula (AVF) stenosis remains an important cause of AVF maturation failure, for which there are currently no effective therapies. We examined the pattern and phenotype of cellular proliferation at different timepoints in a mouse model characterized by a peri-anastomotic AVF stenosis. Methods: Standard immunohistochemical analyses for cellular proliferation and macrophage infiltration were performed at 2, 7 and 14 d on our validated mouse model of AVF stenosis to study the temporal profile, geographical location and cellular phenotype of proliferating and infiltrating cells in this model. Results: Adventitial proliferation and macrophage infiltration (into the adventitia) began at 2 d, peaked at 7 d and then declined over time. Surprisingly, there was minimal macrophage infiltration or proliferation in the neointimal region at either 7 or 14 d, although endothelial cell proliferation increased rapidly between 2 d and 7 d, and peaked at 14 d. Conclusions: Early and rapid macrophage infiltration and cellular proliferation within the adventitia could play an important role in the downstream pathways of both neointimal hyperplasia and inward or outward remodelling.
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Affiliation(s)
- Jenq-Shyong Chan
- Division of Nephrology, Department of Internal Medicine, Armed Forces Taoyuan General Hospital, Taoyuan 325, Taiwan
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
- School of Medicine, National Defense Medical Center, Taipei 114, Taiwan
- Correspondence: (J.-S.C.); (B.C.); Tel.: +886-3-4801611 (J.-S.C.); +1-513-558-0331 (B.C.); Fax: +886-3-4803634 (J.-S.C.)
| | - Yang Wang
- Division of Nephrology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45267, USA;
| | - Virgilius Cornea
- Department of Pathology, University of Cincinnati, Cincinnati, OH 45267, USA;
| | - Prabir Roy-Chaudhury
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, NC 27599, USA;
- WG (Bill) Hefner Salisbury VA Medical Center, Salisbury, NC 27284, USA
| | - Begoña Campos
- Division of Nephrology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45267, USA;
- Correspondence: (J.-S.C.); (B.C.); Tel.: +886-3-4801611 (J.-S.C.); +1-513-558-0331 (B.C.); Fax: +886-3-4803634 (J.-S.C.)
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6
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Vazquez-Padron RI, Duque JC, Tabbara M, Salman LH, Martinez L. Intimal Hyperplasia and Arteriovenous Fistula Failure: Looking Beyond Size Differences. KIDNEY360 2021; 2:1360-1372. [PMID: 34765989 PMCID: PMC8579754 DOI: 10.34067/kid.0002022021] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The development of venous intimal hyperplasia (IH) has been historically associated with failure of arteriovenous fistulas (AVF) used for hemodialysis. This long-standing assumption, based on histological observations, has been recently challenged by clinical studies indicating that the size of the intima by itself is not enough to explain stenosis or AVF maturation failure. Irrespective of this lack of association, IH is present in most native veins and fistulas, is prominent in many cases, and suggests a role in the vein that may not be reflected by its dimensions. Therefore, the contribution of IH to AVF dysfunction remains controversial. Using only clinical data and avoiding extrapolations from animal models, we critically discuss the biological significance of IH in vein remodeling, vascular access function, and the response of the venous wall to repeated trauma in hemodialysis patients. We address questions and pose new ones such as: What are the factors that contribute to IH in pre-access veins and AVFs? Do cellular phenotypes and composition of the intima influence AVF function? Are there protective roles of the venous intima? This review explores these possibilities, with hopes of rekindling a critical discussion about venous IH that goes beyond thickness and AVF outcomes.
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Affiliation(s)
- Roberto I Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Juan C Duque
- Katz Family Division of Nephrology, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Marwan Tabbara
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
| | - Loay H Salman
- Division of Nephrology, Albany Medical College, Albany, New York
| | - Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, Florida
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7
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Mohamed I, Kamarizan MFA, Da Silva A. Medical adjuvant treatment to increase patency of arteriovenous fistulae and grafts. Cochrane Database Syst Rev 2021; 7:CD002786. [PMID: 34298589 PMCID: PMC8406473 DOI: 10.1002/14651858.cd002786.pub4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND People with end-stage renal disease (ESRD) often require either the formation of an arteriovenous fistula (AVF) or an interposition prosthetic arteriovenous graft (AVG) for haemodialysis. These access sites should ideally have a long life and a low rate of complications (e.g. thrombosis, infection, stenosis, aneurysm formation and distal limb ischaemia). Although some of the complications may be unavoidable, any adjuvant technique or medical treatment aimed at decreasing complications would be welcome. This is the fourth update of the review first published in 2003. OBJECTIVES To assess the effects of adjuvant drug treatment in people with ESRD on haemodialysis via autologous AVFs or prosthetic interposition AVGs. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and ClinicalTrials.gov trials register to 6 August 2020. SELECTION CRITERIA Randomised controlled trials of active drug versus placebo in people with ESRD undergoing haemodialysis via an AVF or prosthetic interposition AVG. DATA COLLECTION AND ANALYSIS For this update, two review authors (IM, MFAK) independently selected trials for inclusion, extracted data, assessed risk of bias and assessed the certainty of the evidence according to GRADE. We resolved disagreements by discussion or consultation with another review author (ADS). The primary outcome was the long-term fistula or graft patency rate. Secondary outcomes included duration of hospital stay; complications such as infection, aneurysm formation, stenosis and distal limb ischaemia; and number of related surgical or radiological interventions. MAIN RESULTS For this update, one additional study was suitable for inclusion, making a total of 13 trials with 2080 participants. Overall the certainty of the evidence was low or moderate due to short follow-up periods, heterogeneity between trials, small sample sizes, and risk of bias due to incomplete reporting. Medical adjuvant treatments used in the included trials were aspirin, ticlopidine, dipyridamole, dipyridamole plus aspirin, warfarin, fish oil, clopidogrel, sulphinpyrazone and glyceryl trinitrate (GTN) patch. All included studies reported on graft patency by measuring graft thrombosis. There was insufficient evidence to determine if there was a difference in graft patency in studies comparing aspirin versus placebo (odds ratio (OR) 0.40, 95% confidence interval (CI) 0.07 to 2.25; 3 studies, 175 participants; low-certainty evidence). The meta-analysis for graft patency comparing ticlopidine versus placebo favoured ticlopidine (OR 0.45, 95% CI 0.25 to 0.82; 3 studies, 339 participants; moderate-certainty evidence). There was insufficient evidence to determine if there was a difference in graft patency in studies comparing fish oil versus placebo (OR 0.24, 95% CI 0.03 to 1.95; 2 studies, 220 participants; low-certainty evidence); and studies comparing clopidogrel and placebo (OR 0.40, 95% CI 0.13 to 1.19; 2 studies, 959 participants; moderate-certainty evidence). Similarly, there was insufficient evidence to determine if there was a difference in graft patency comparing the effect of dipyridamole versus placebo (OR 0.46, 95% CI 0.11 to 1.94; 1 study, 42 participants, moderate-certainty evidence) and dipyridamole plus aspirin versus placebo (OR 0.64, CI 0.16 to 2.56; 1 study, 41 participants; moderate-certainty evidence); comparing low-intensity warfarin with placebo (OR 1.76, 95% CI 0.78 to 3.99; 1 study, 107 participants; low-certainty evidence); comparing sulphinpyrazone versus placebo (OR 0.43, 95% CI 0.03 to 5.98; 1 study, 16 participants; low-certainty evidence) and comparing GTN patch and placebo (OR 1.26, 95% CI 0.63 to 2.54; 1 study, 167 participants; moderate-certainty evidence). The single trial evaluating warfarin was terminated early because of major bleeding events in the warfarin group. Only two studies published data on the secondary outcome of related interventions (surgical or radiological); there was insufficient evidence to determine if there was a difference in related interventions between placebo and treatment groups. None of the included studies reported on the duration of hospital stay. Most studies reported complications ranging from mortality to nausea. However, data on complications were limited and reporting varied between studies. AUTHORS' CONCLUSIONS The meta-analyses of three studies for ticlopidine (an antiplatelet treatment), which all used the same dose of treatment but with a short follow-up of only one month, suggest ticlopidine may have a beneficial effect as an adjuvant treatment to increase the patency of AVFs and AVGs in the short term. There was insufficient evidence to determine if there was a difference in graft patency between placebo and other treatments such as aspirin, fish oil, clopidogrel, dipyridamole, dipyridamole plus aspirin, warfarin, sulphinpyrazone and GTN patch. The certainty of the evidence was low to moderate due to short follow-up periods, the small number of studies for each comparison, small sample sizes, heterogeneity between trials and risk of bias due to incomplete reporting. Therefore, it appears reasonable to suggest further prospective studies be undertaken to assess the use of these antiplatelet drugs in renal patients with an AVF or AVG.
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Affiliation(s)
- Imran Mohamed
- Wales Deanery, Health Education and Improvement Wales, Nantgarw, UK
| | | | - Antonio Da Silva
- Department of Vascular Surgery, Wrexham Maelor Hospital, Wrexham, UK
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8
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Bai H, Sadaghianloo N, Gorecka J, Liu S, Ono S, Ramachandra AB, Bonnet S, Mazure NM, Declemy S, Humphrey JD, Dardik A. Artery to vein configuration of arteriovenous fistula improves hemodynamics to increase maturation and patency. Sci Transl Med 2021; 12:12/557/eaax7613. [PMID: 32817365 DOI: 10.1126/scitranslmed.aax7613] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 03/17/2020] [Accepted: 06/09/2020] [Indexed: 12/21/2022]
Abstract
Arteriovenous fistulae (AVF) are the preferred mode of hemodialysis access, but 60% of conventional [vein-to-artery (V-A)] AVF fail to mature, and only 50% remain patent at 1 year. We previously showed improved maturation and patency in a pilot study of the radial artery deviation and reimplantation (RADAR) technique that uses an artery-to-vein (A-V) configuration. Here, we show that RADAR exhibits higher rates of maturation, as well as increased primary and secondary long-term patencies. RADAR is also protective in female patients, where it is associated with decreased reintervention rates and improved secondary patency. RADAR and conventional geometries were compared further in a rat bilateral carotid artery-internal jugular vein fistula model. There was decreased cell proliferation and neointimal hyperplasia in the A-V configuration in male and female animals, but no difference in hypoxia between the A-V and V-A configurations. Similar trends were seen in uremic male rats. The A-V configuration also associated with increased peak systolic velocity and expression of Kruppel-like factor 2 and phosphorylated endothelial nitric oxide synthase, consistent with improved hemodynamics. Computed tomography and ultrasound-informed computational modeling showed different hemodynamics in the A-V and V-A configurations, and improving the hemodynamics in the V-A configuration was protective against neointimal hyperplasia. These findings collectively demonstrate that RADAR is a durable surgical option for patients requiring radial-cephalic AVF for hemodialysis access.
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Affiliation(s)
- Hualong Bai
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT 06520, USA.,Department of Surgery, Yale School of Medicine, New Haven, CT 06520, USA.,Department of Vascular and Endovascular Surgery, First Affiliated Hospital of Zhengzhou University, Key Vascular Physiology and Applied Research Laboratory of Zhengzhou City, Henan 450052, China
| | - Nirvana Sadaghianloo
- Université Côte d'Azur, Centre Méditerranéen de Médecine Moléculaire, INSERM 1065, 06200 Nice, France.,Centre Hospitalier Universitaire de Nice, Department of Vascular Surgery, 06000 Nice, France
| | - Jolanta Gorecka
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT 06520, USA.,Department of Surgery, Yale School of Medicine, New Haven, CT 06520, USA
| | - Shirley Liu
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT 06520, USA.,Department of Surgery, Yale School of Medicine, New Haven, CT 06520, USA
| | - Shun Ono
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT 06520, USA
| | - Abhay B Ramachandra
- Department of Biomedical Engineering, Yale University, New Haven, CT 06520, USA
| | - Sophie Bonnet
- Centre Hospitalier Universitaire de Nice, Department of Vascular Surgery, 06000 Nice, France
| | - Nathalie M Mazure
- Université Côte d'Azur, Centre Méditerranéen de Médecine Moléculaire, INSERM 1065, 06200 Nice, France
| | - Serge Declemy
- Centre Hospitalier Universitaire de Nice, Department of Vascular Surgery, 06000 Nice, France
| | - Jay D Humphrey
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT 06520, USA.,Department of Biomedical Engineering, Yale University, New Haven, CT 06520, USA
| | - Alan Dardik
- Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, CT 06520, USA. .,Department of Surgery, Yale School of Medicine, New Haven, CT 06520, USA.,Division of Vascular and Endovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT 06519, USA.,Department of Surgery, VA Connecticut Healthcare System, West Haven, CT 06516, USA
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9
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Peden EK, Lucas JF, Browne BJ, Settle SM, Scavo VA, Bleyer AJ, Ozaki CK, Teruya TH, Wilson SE, Mishler RE, Ferris BL, Hendon KS, Moist L, Dixon BS, Wong MD, Magill M, Lindow F, Gustafson P, Burke SK. PATENCY-2 trial of vonapanitase to promote radiocephalic fistula use for hemodialysis and secondary patency. J Vasc Access 2021; 23:265-274. [PMID: 33482699 DOI: 10.1177/1129729820985626] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Arteriovenous fistulas created for hemodialysis often fail to become usable and are frequently abandoned. This prospective trial evaluated the efficacy of vonapanitase, a recombinant human elastase, in increasing radiocephalic fistula use for hemodialysis and secondary patency. METHODS PATENCY-2 was a randomized, double-blind, placebo-controlled trial in patients on or approaching the need for hemodialysis undergoing radiocephalic arteriovenous fistula creation. Of 696 screened, 613 were randomized, and 603 were treated (vonapanitase n = 405, placebo n = 208). The study drug solution was applied topically to the artery and vein for 10 min immediately after fistula creation. The primary endpoints were fistula use for hemodialysis and secondary patency (fistula survival without abandonment). Other efficacy endpoints included unassisted fistula use for hemodialysis, primary unassisted patency, fistula maturation and unassisted maturation by ultrasound criteria, and fistula procedure rates. RESULTS The proportions of patients with fistula use for hemodialysis was similar between groups, 70% vonapanitase and 65% placebo, (p = 0.33). The Kaplan-Meier estimates of 12-month secondary patency were 78% (95% confidence interval [CI], 73-82) for vonapanitase and 76% (95% CI, 70-82) for placebo (p = 0.93). The proportions with unassisted fistula use for hemodialysis were 46% vonapanitase and 37% placebo (p = 0.054). The Kaplan-Meier estimates of 12-month primary unassisted patency were 50% (95% CI, 44-55) for vonapanitase and 43% (95% CI, 35-50) for placebo (p = 0.18). There were no differences in the proportion of patients with fistula maturation or in fistula procedure rates. Adverse events were similar between groups. Vonapanitase was not immunogenic. CONCLUSIONS Vonapanitase treatment did not achieve clinical or statistical significance to meaningfully improve radiocephalic fistula surgical outcomes. Outcome in the placebo group were better than in historical controls. Vonapanitase was well-tolerated and safe. TRIAL REGISTRATION clinicaltrials.gov: NCT02414841 (https://clinicaltrials.gov/ct2/show/NCT02414841).
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Affiliation(s)
| | - John F Lucas
- Surgery, Greenwood Leflore Hospital, Greenwood, MS, USA
| | | | | | | | | | | | - Theodore H Teruya
- Cardiovascular and Thoracic Surgery, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Samuel E Wilson
- Vascular Surgery, University of California Irvine Medical Center, Irvine, CA, USA
| | - Rick E Mishler
- Arizona Kidney Disease & Hypertension Centers, Phoenix, AZ, USA
| | | | | | - Louise Moist
- Division of Nephrology, Western University, London, ON, Canada
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10
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Lawson JH, Niklason LE, Roy-Chaudhury P. Challenges and novel therapies for vascular access in haemodialysis. Nat Rev Nephrol 2020; 16:586-602. [PMID: 32839580 PMCID: PMC8108319 DOI: 10.1038/s41581-020-0333-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2020] [Indexed: 02/07/2023]
Abstract
Advances in standards of care have extended the life expectancy of patients with kidney failure. However, options for chronic vascular access for haemodialysis - an essential part of kidney replacement therapy - have remained unchanged for decades. The high morbidity and mortality associated with current vascular access complications highlights an unmet clinical need for novel techniques in vascular access and is driving innovation in vascular access care. The development of devices, biological approaches and novel access techniques has led to new approaches to controlling fistula geometry and manipulating the underlying cellular and molecular pathways of the vascular endothelium, and influencing fistula maturation and formation through the use of external mechanical methods. Innovations in arteriovenous graft materials range from small modifications to the graft lumen to the creation of completely novel bioengineered grafts. Steps have even been taken to create new devices for the treatment of patients with central vein stenosis. However, these emerging therapies face difficult hurdles, and truly creative approaches to vascular access need resources that include well-designed clinical trials, frequent interaction with regulators, interventionalist education and sufficient funding. In addition, the heterogeneity of patients with kidney failure suggests it is unlikely that a 'one-size-fits-all' approach for effective vascular access will be feasible in the current environment.
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Affiliation(s)
- Jeffrey H Lawson
- Department of Surgery, Duke University, Durham, NC, USA.
- Humacyte, Inc., Durham, NC, USA.
| | - Laura E Niklason
- Humacyte, Inc., Durham, NC, USA
- School of Engineering & Applied Science, Yale University, New Haven, CT, USA
| | - Prabir Roy-Chaudhury
- University of North Carolina Kidney Center, Chapel Hill, NC, USA
- WG (Bill) Hefner VA Medical Center, Salisbury, NC, USA
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11
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Mo YW, Sun CY, Song L, Zhou LF, Zhuang TT, Zhong M, Zheng SQ, Chen YG, Chen YH, Liu SX, Liang XL, Fu X. How to carry out monthly blood flow surveillance of fistula in large-scale hemodialysis units: A cross-sectional study. J Vasc Access 2020; 22:75-80. [PMID: 32476548 DOI: 10.1177/1129729820923939] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The important effect of regular blood flow surveillance on arteriovenous fistula maintenance is emphasized. The ultrasonic dilution technique for blood flow surveillance can be performed during hemodialysis, but there are some limitations. Blood flow is traditionally measured by duplex Doppler ultrasound during the nondialysis period. However, the surveillance workload for arteriovenous fistula has increased with the rapid increase in the hemodialysis population size. Efficient methods for blood flow surveillance during hemodialysis are needed. METHODS Eighty-four hemodialysis patients with a forearm radiocephalic arteriovenous fistula were enrolled in this cross-sectional study. Each received blood flow measurements using ultrasonic dilution technique and duplex Doppler ultrasound during hemodialysis. Duplex Doppler ultrasound measurements included the blood flow of the brachial artery and radial artery. The correlations between these variables were analyzed. RESULTS The correlation coefficients (r) between flow measured by ultrasonic dilution technique and brachial artery flow measured by duplex Doppler ultrasound, between flow measured by ultrasonic dilution technique and radial artery flow measured by duplex Doppler ultrasound, and between brachial artery flow and radial artery flow measured by duplex Doppler ultrasound were 0.724, 0.784, and 0.749, respectively (all p < 0.001). CONCLUSION Blood flow measured by ultrasonic dilution technique was positively correlated with blood flow measured by duplex Doppler ultrasound during hemodialysis, suggesting that duplex Doppler ultrasound can be used to monitor the trends in the blood flow of the brachial artery and radial artery for timely intervention to improve patency during hemodialysis.
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Affiliation(s)
- Ya-Wen Mo
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,School of Nursing, Southern Medical University, Guangzhou, China.,Ya-wen Mo and Chun-yan Sun contributed equally to the article
| | - Chun-Yan Sun
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,School of Nursing, Southern Medical University, Guangzhou, China.,Ya-wen Mo and Chun-yan Sun contributed equally to the article
| | - Li Song
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Li-Fang Zhou
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,School of Nursing, Southern Medical University, Guangzhou, China
| | - Ting-Ting Zhuang
- Department of Rehabilitation Medicine, Guangdong Second Traditional Chinese Medicine Hospital, Guangzhou, China
| | - Mi Zhong
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shu-Qian Zheng
- School of Nursing, Southern Medical University, Guangzhou, China.,Division of Nephrology, Guangzhou Nansha Central Hospital, Guangzhou, China
| | - Ying-Gui Chen
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,School of Nursing, Southern Medical University, Guangzhou, China
| | - Yuan-Han Chen
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shuang-Xin Liu
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xin-Ling Liang
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xia Fu
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,School of Nursing, Southern Medical University, Guangzhou, China
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12
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Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, Allon M, Asif A, Astor BC, Glickman MH, Graham J, Moist LM, Rajan DK, Roberts C, Vachharajani TJ, Valentini RP. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis 2020; 75:S1-S164. [PMID: 32778223 DOI: 10.1053/j.ajkd.2019.12.001] [Citation(s) in RCA: 952] [Impact Index Per Article: 238.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 12/09/2019] [Indexed: 02/07/2023]
Abstract
The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.
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13
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Thajudeen B, Murugapandian S, Roy-Chaudhury P. Emerging Therapies. CHRONIC RENAL DISEASE 2020:1189-1205. [DOI: 10.1016/b978-0-12-815876-0.00072-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/19/2023]
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14
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Gorecka J, Fereydooni A, Gonzalez L, Lee SR, Liu S, Ono S, Xu J, Liu J, Taniguchi R, Matsubara Y, Gao X, Gao M, Langford J, Yatsula B, Dardik A. Molecular Targets for Improving Arteriovenous Fistula Maturation and Patency. VASCULAR INVESTIGATION AND THERAPY 2019; 2:33-41. [PMID: 31608322 DOI: 10.4103/vit.vit_9_19] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The increasing prevalence of chronic and end-stage renal disease creates an increased need for reliable vascular access, and although arteriovenous fistulae (AVF) are the preferred mode of hemodialysis access, 60% fail to mature and only 50% remain patent at one year. Fistulae mature by diameter expansion and wall thickening; this outward remodeling of the venous wall in the fistula environment relies on a delicate balance of extracellular matrix (ECM) remodeling, inflammation, growth factor secretion, and cell adhesion molecule upregulation in the venous wall. AVF failure occurs via two distinct mechanisms with early failure secondary to lack of outward remodeling, that is insufficient diameter expansion or wall thickening, whereas late failure occurs with excessive wall thickening due to neointimal hyperplasia (NIH) and insufficient diameter expansion in a previously functional fistula. In recent years, the molecular basis of AVF maturation and failure are becoming understood in order to develop potential therapeutic targets to aide maturation and prevent access loss. Erythropoietin-producing hepatocellular carcinoma (Eph) receptors, along with their ligands, ephrins, determine vascular identity and are critical for vascular remodeling in the embryo. Manipulation of Eph receptor signaling in adults, as well as downstream pathways, is a potential treatment strategy to improve the rates of AVF maturation and patency. This review examines our current understanding of molecular changes occurring following fistula creation, factors predictive of fistula success, and potential areas of intervention to decrease AVF failure.
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Affiliation(s)
- Jolanta Gorecka
- Vascular Biology and Therapeutics Program and the Department of Surgery, Yale School of Medicine, Yale University, New Haven, USA
| | - Arash Fereydooni
- Vascular Biology and Therapeutics Program and the Department of Surgery, Yale School of Medicine, Yale University, New Haven, USA
| | - Luis Gonzalez
- Vascular Biology and Therapeutics Program and the Department of Surgery, Yale School of Medicine, Yale University, New Haven, USA
| | - Shin Rong Lee
- Vascular Biology and Therapeutics Program and the Department of Surgery, Yale School of Medicine, Yale University, New Haven, USA
| | - Shirley Liu
- Vascular Biology and Therapeutics Program and the Department of Surgery, Yale School of Medicine, Yale University, New Haven, USA
| | - Shun Ono
- Vascular Biology and Therapeutics Program and the Department of Surgery, Yale School of Medicine, Yale University, New Haven, USA
| | - Jianbiao Xu
- Vascular Biology and Therapeutics Program and the Department of Surgery, Yale School of Medicine, Yale University, New Haven, USA
| | - Jia Liu
- Vascular Biology and Therapeutics Program and the Department of Surgery, Yale School of Medicine, Yale University, New Haven, USA.,The Third Xiangya Hospital, Central South University, Changsha, Hunan, China.,Department of Vascular Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Ryosuke Taniguchi
- Vascular Biology and Therapeutics Program and the Department of Surgery, Yale School of Medicine, Yale University, New Haven, USA
| | - Yutaka Matsubara
- Vascular Biology and Therapeutics Program and the Department of Surgery, Yale School of Medicine, Yale University, New Haven, USA
| | - Xixiang Gao
- Vascular Biology and Therapeutics Program and the Department of Surgery, Yale School of Medicine, Yale University, New Haven, USA.,Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Mingjie Gao
- Vascular Biology and Therapeutics Program and the Department of Surgery, Yale School of Medicine, Yale University, New Haven, USA.,Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - John Langford
- Vascular Biology and Therapeutics Program and the Department of Surgery, Yale School of Medicine, Yale University, New Haven, USA
| | - Bogdan Yatsula
- Vascular Biology and Therapeutics Program and the Department of Surgery, Yale School of Medicine, Yale University, New Haven, USA
| | - Alan Dardik
- Vascular Biology and Therapeutics Program and the Department of Surgery, Yale School of Medicine, Yale University, New Haven, USA.,Section of Vascular and Endovascular Surgery, VA Connecticut Healthcare System, West Haven, USA
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15
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Gameiro J, Ibeas J. Factors affecting arteriovenous fistula dysfunction: A narrative review. J Vasc Access 2019; 21:134-147. [PMID: 31113281 DOI: 10.1177/1129729819845562] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Vascular access dysfunction is one of the most important causes of morbidity and mortality in haemodialysis patients, contributing to up to one third of hospitalisations and accounting for a significant amount of the health care costs of these patients. In the past decades, significant scientific advances in understanding mechanisms of arteriovenous fistula maturation and failure have contributed to an increase in the amount of research into techniques for creation and strategies for arteriovenous fistula dysfunction prevention and treatment, in order to improve patient care and outcomes. The aim of this review is to describe the pathogenesis of vascular access failure and provide a comprehensive analysis of the associated risk factors and causes of vascular access failure, in order to interpret possible future therapeutic approaches. Arteriovenous fistula failure is a multifactorial process resulting from the combination of upstream and downstream events with consequent venous neo-intimal hyperplasia and/or inadequate outward remodelling. Inflammation appears to be central in the biology of arteriovenous fistula dysfunction but important triggers still need to be revealed. Given the significant association of arteriovenous fistula failure and patient's prognosis, it is therefore imperative to further research in this area in order to improve prevention, surveillance and treatment, and ultimately patient care and outcomes.
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Affiliation(s)
- Joana Gameiro
- Division of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, EPE, Lisboa, Portugal
| | - Jose Ibeas
- Nephrology Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
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16
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A randomized trial of vonapanitase (PATENCY-1) to promote radiocephalic fistula patency and use for hemodialysis. J Vasc Surg 2019; 69:507-515. [PMID: 30683197 DOI: 10.1016/j.jvs.2018.04.068] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 04/09/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Arteriovenous fistulas created in patients with chronic kidney disease often lose patency and fail to become usable. This prospective trial evaluated the efficacy of vonapanitase, a recombinant human elastase, in promoting radiocephalic fistula patency and use for hemodialysis. METHODS PATENCY-1 was a double-blind, placebo-controlled trial that enrolled 349 patients on or approaching hemodialysis and being evaluated for radiocephalic arteriovenous fistula creation. Of these, 313 were randomized and 311 treated. Patients were assigned to vonapanitase (n = 210) or placebo (n = 103). The study drug solution was applied topically to the artery and vein for 10 minutes immediately after fistula creation. The primary and secondary end points were primary patency (time to first thrombosis or corrective procedure) and secondary patency (time to abandonment). Tertiary end points included use of the fistula for hemodialysis, fistula maturation by ultrasound, and procedure rates. RESULTS The Kaplan-Meier estimates of 12-month primary patency were 42% (95% confidence interval [CI], 35-49) and 31% (95% CI, 21-42) for vonapanitase and placebo (P = .25). The Kaplan-Meier estimates of 12-month secondary patency were 74% (95% CI, 68-80) and 61% (95% CI, 51-71) for vonapanitase and placebo (P = .048). The proportions of vonapanitase and placebo patients were 39% and 25% (P = .035) with unassisted use for hemodialysis and 64% and 44% (P = .006) with unassisted plus assisted use. CONCLUSIONS Vonapanitase treatment did not significantly improve primary patency but was associated with increased secondary patency and use for hemodialysis. Further research is needed to evaluate these end points.
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17
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Near-Infrared Fluorescence Imaging of Matrix Metalloproteinase 2 Activity as a Biomarker of Vascular Remodeling in Hemodialysis Access. J Vasc Interv Radiol 2018; 29:1268-1275.e1. [PMID: 30061060 DOI: 10.1016/j.jvir.2018.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 04/19/2018] [Accepted: 04/30/2018] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To establish the capability of near-infrared fluorescence (NIRF) imaging for the detection of matrix metalloproteinase 2 (MMP-2) activity as a biomarker of vascular remodeling (VR) in arteriovenous fistulae (AVFs) in vivo. MATERIALS AND METHODS AVFs were created in the right groins of Wistar rats (n = 10), and sham procedures were performed in the contralateral groins. Fistulography via a left common carotid artery approach confirmed stenosis (> 50%) in a subset of animals (n = 5) 4 weeks after AVF creation. After administration of MMP-2-activated NIRF probe, near-infrared imaging was performed in vivo and ex vivo of both the AVF and the sham-treated vessels to measure radiant efficiency of MMP-2-activated NIRF signal over background. Histologic analyses of AVF and sham-treated vessels were performed to measure VR defined as inward growth of the vessel caused by intimal thickening. RESULTS AVFs demonstrated a significantly higher percentage increase in radiant efficiency over background compared with sham vessels (45.5 ± 56% vs 16.1 ± 17.8%; P = .008). VR in AVFs was associated with increased thickness of neointima staining positively for MMP-2 (161.8 ± 45.5 μm vs 73.2 ± 36.7 μm; P = .01). A significant correlation was observed between MMP-2 activity as measured by relative increase in radiant efficiency for AVFs and thickness of neointima staining positively for MMP-2 (P = .039). CONCLUSIONS NIRF imaging can detect increased MMP activity in remodeled AVFs compared with contralateral sham vessels. MMP-2-activated NIRF signal correlates with the severity of intimal thickening. These findings suggest NIRF imaging of MMP-2 may be used as a biomarker of the vascular remodeling underlying stenosis.
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18
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Kokkinidis DG, Armstrong EJ. Emerging and Future Therapeutic Options for Femoropopliteal and Infrapopliteal Endovascular Intervention. Interv Cardiol Clin 2017; 6:279-295. [PMID: 28257775 DOI: 10.1016/j.iccl.2016.12.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Despite recent advances in endovascular therapy for peripheral artery disease, current technologies remain limited by rates of long-term restenosis and application to complex lesion subsets. This article presents data on upcoming therapies, including novel drug-coated balloons, drug-eluting stents, bioresorbable scaffolds, novel drug delivery therapies to target arteries, techniques to limit postangioplasty dissection, and treatment of severely calcified lesions.
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Affiliation(s)
- Damianos G Kokkinidis
- Section of Cardiology, Denver VA Medical Center, University of Colorado School of Medicine, 1055 Clermont Street, Denver, CO 80220, USA
| | - Ehrin J Armstrong
- Section of Cardiology, Denver VA Medical Center, University of Colorado School of Medicine, 1055 Clermont Street, Denver, CO 80220, USA.
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19
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Surgical technique determines the outcome of the Brescia/Cimino AVF. J Vasc Access 2017; 18:1-4. [PMID: 28297045 DOI: 10.5301/jva.5000698] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2017] [Indexed: 12/19/2022] Open
Abstract
Over the past 50 years, since Dr. Appel performed the first internal vascular access procedure for hemodialysis, the distal radiocephalic arteriovenous fistula continues to be the access of choice. Over time, failure to maturation has evolved as a major problem associated with this procedure depriving its benefits to many patients with end-stage renal disease. A variable incidence of this problem within similar patients suggests that surgical technique may play an important role in the development of non-maturation. Evaluating the current surgical techniques based on the hemodynamic consequences of anatomic and physiologic alterations following this procedure highlights the role of surgical technique in mitigating or reducing complications. Piggy-back straight line on-lay, a technique that helps to tailor the blood flow and reduce the oscillatory shear stress appears to reduce the incidence of early juxta-anastomotic problems, which contribute significantly to the problem of non-maturation.
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20
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Abstract
Supplemental Digital Content is Available in the Text. Purpose: This study was designed to determine whether vonapanitase (formerly PRT-201),
a recombinant human elastase, treatment can fragment the protein elastin in
elastic fibers and cause dilation of atherosclerotic human peripheral
arteries subjected to ex vivo balloon angioplasty. Materials and Methods: Seven patients undergoing lower limb amputation for peripheral artery disease
or who died and donated their bodies to science donated 11 tibial arteries
(5 anterior, 6 posterior) for this study. All arteries were atherosclerotic
by visual inspection. The arteries underwent ex vivo balloon angioplasty and
thereafter were cut into rings and studied on wire myographs where the rings
were stretched and tension was recorded. After treatment with vonapanitase 2
mg/mL or vehicle control, myography was repeated and the rings were then
subject to elastin content measurement using a desmosine radioimmunoassay
and elastic fiber visualization by histology. The wire myography data were
used to derive compliance, stress-strain, and incremental elastic modulus
curves. Results: Vonapanitase treatment reduced elastin (desmosine) content by 60% and
decreased elastic fiber histologic staining. Vonapanitase-treated rings
experienced less tension at any level of stretch and as a result had shifts
in the compliance and stress-strain curves relative to vehicle-treated
rings. Vonapanitase treatment did not alter the incremental elastic modulus
curve. Conclusions: Vonapanitase treatment of atherosclerotic human peripheral arteries after ex
vivo balloon angioplasty fragmented elastin in elastic fibers, decreased
tension in the rings at any level of stretch, and altered the compliance and
stress-strain curves in a manner predicting arterial dilation in vivo. Based
on this result, local treatment of balloon angioplasty sites may increase
blood vessel diameter and thereby improve the success of balloon angioplasty
in peripheral artery disease.
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21
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Peden EK, O'Connor TP, Browne BJ, Dixon BS, Schanzer AS, Jensik SC, Sam AD, Burke SK. Arteriovenous fistula patency in the 3 years following vonapanitase and placebo treatment. J Vasc Surg 2016; 65:1113-1120. [PMID: 27986480 DOI: 10.1016/j.jvs.2016.08.101] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 08/08/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This study explored the long-term outcomes of arteriovenous fistulas treated with vonapanitase (recombinant human elastase) at the time of surgical creation. METHODS This was a randomized, double-blind, placebo-controlled trial of 151 patients undergoing radiocephalic or brachiocephalic arteriovenous fistula creation who were randomized equally to placebo, vonapanitase 10 μg, or vonapanitase 30 μg. The results after 1 year of follow-up were previously reported. The current analysis occurred when the last patient treated was observed for 3 years. For the current analysis, the primary end point was primary patency; the secondary end points included secondary patency, use of the fistula for hemodialysis, and rate of procedures to restore or to maintain patency. RESULTS There was no significant difference in the risk of primary patency loss with vonapanitase 10 μg or 30 μg vs placebo. When seven initial patency loss events related to cephalic arch and central vein balloon angioplasty were excluded, the risk of patency loss was reduced with vonapanitase overall (hazard ratio [HR], 0.63; P = .049) and 30 μg (HR, 0.51; P = .03). In patients with radiocephalic fistulas (n = 67), the risks of primary and secondary patency loss were reduced with 30 μg (HR, 0.37 [P = .02] and 0.24 [P = .046], respectively). The rate of procedures to restore or to maintain fistula patency was reduced with 30 μg vs placebo (0.23 vs 0.72 procedure days/patient/year; P = .03) and also reduced in patients with radiocephalic fistulas with 30 μg vs placebo (0.17 vs 0.85 procedure days/patient/year; P = .048). CONCLUSIONS In this study, vonapanitase did not significantly improve primary patency in the primary analysis but did significantly improve primary patency in an analysis that excluded patency loss due to cephalic arch and central vein balloon angioplasty. In patients with radiocephalic fistulas, 30 μg significantly improved primary and secondary patency. Vonapanitase 30 μg decreased the rate of procedures to restore or to maintain patency in the analysis that included all patients and in the subset with radiocephalic fistulas.
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Affiliation(s)
- Eric K Peden
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, Tex
| | | | - Barry J Browne
- California Institute of Renal Research, San Diego, Calif
| | - Bradley S Dixon
- Department of Medicine, University of Iowa Hospital and Clinics, Iowa City, Iowa
| | - Andres S Schanzer
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, Mass
| | - Stephen C Jensik
- Transplant Program, Rush University Medical Center, Chicago, Ill
| | - Albert D Sam
- Tulane University Heart and Vascular Institute, New Orleans, La
| | - Steven K Burke
- Research and Development, Proteon Therapeutics, Inc, Waltham, Mass.
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22
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Duque JC, Tabbara M, Martinez L, Cardona J, Vazquez-Padron RI, Salman LH. Dialysis Arteriovenous Fistula Failure and Angioplasty: Intimal Hyperplasia and Other Causes of Access Failure. Am J Kidney Dis 2016; 69:147-151. [PMID: 28084215 DOI: 10.1053/j.ajkd.2016.08.025] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 08/02/2016] [Indexed: 12/27/2022]
Abstract
The arteriovenous fistula (AVF) is the preferred hemodialysis access type because it has better patency rates and fewer complications than other access types. However, primary failure remains a common problem impeding AVF maturation and adding to patients' morbidity and mortality. Juxta-anastomotic (or inflow) stenosis is the most common reason leading to primary failure, and percutaneous transluminal angioplasty continues to be the gold-standard treatment with excellent success rates. Intimal hyperplasia (IH) has been traditionally blamed as the main pathophysiologic culprit, but new evidence raises doubts regarding the contribution of IH alone to primary failure. We report a 64-year-old man with a 2-stage brachiobasilic AVF that was complicated by failure 4 months after creation. An angiogram showed multiple juxta-anastomotic and midfistula stenotic lesions. Percutaneous transluminal angioplasty was successful in assisting maturation and subsequently cannulating the AVF for hemodialysis treatment. We failed to identify the underlying cause of stenosis because biopsy specimens from fistula tissue obtained at the time of transposition revealed no occlusive IH. This case emphasizes the need for additional research on factors contributing to AVF failure besides IH and highlights the need for more therapeutic options to reduce AVF failure rate.
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Affiliation(s)
- Juan C Duque
- Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Marwan Tabbara
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Laisel Martinez
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Jose Cardona
- Division of Nephrology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Roberto I Vazquez-Padron
- DeWitt Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL
| | - Loay H Salman
- Section of Interventional Nephrology, Leonard M. Miller School of Medicine, University of Miami, Miami, FL.
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Hu H, Patel S, Hanisch JJ, Santana JM, Hashimoto T, Bai H, Kudze T, Foster TR, Guo J, Yatsula B, Tsui J, Dardik A. Future research directions to improve fistula maturation and reduce access failure. Semin Vasc Surg 2016; 29:153-171. [PMID: 28779782 DOI: 10.1053/j.semvascsurg.2016.08.005] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
With the increasing prevalence of end-stage renal disease, there is a growing need for hemodialysis. Arteriovenous fistulae (AVF) are the preferred type of vascular access for hemodialysis, but maturation and failure continue to present significant barriers to successful fistula use. AVF maturation integrates outward remodeling with vessel wall thickening in response to drastic hemodynamic changes in the setting of uremia, systemic inflammation, oxidative stress, and pre-existent vascular pathology. AVF can fail due to both failure to mature adequately to support hemodialysis and development of neointimal hyperplasia that narrows the AVF lumen, typically near the fistula anastomosis. Failure due to neointimal hyperplasia involves vascular cell activation and migration and extracellular matrix remodeling with complex interactions of growth factors, adhesion molecules, inflammatory mediators, and chemokines, all of which result in maladaptive remodeling. Different strategies have been proposed to prevent and treat AVF failure based on current understanding of the modes and pathology of access failure; these approaches range from appropriate patient selection and use of alternative surgical strategies for fistula creation, to the use of novel interventional techniques or drugs to treat failing fistulae. Effective treatments to prevent or treat AVF failure require a multidisciplinary approach involving nephrologists, vascular surgeons, and interventional radiologists, careful patient selection, and the use of tailored systemic or localized interventions to improve patient-specific outcomes. This review provides contemporary information on the underlying mechanisms of AVF maturation and failure and discusses the broad spectrum of options that can be tailored for specific therapy.
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Affiliation(s)
- Haidi Hu
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Department of Vascular and Thyroid Surgery, the First Affiliated Hospital of China Medical University, Shenyang, China; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT
| | - Sandeep Patel
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT; Royal Free Hospital, University College London, London, UK
| | - Jesse J Hanisch
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT
| | - Jeans M Santana
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT
| | - Takuya Hashimoto
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT
| | - Hualong Bai
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT
| | - Tambudzai Kudze
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT
| | - Trenton R Foster
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT
| | - Jianming Guo
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT
| | - Bogdan Yatsula
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT
| | - Janice Tsui
- Royal Free Hospital, University College London, London, UK
| | - Alan Dardik
- Department of Surgery, Yale University School of Medicine, 10 Amistad Street, Room 437, PO Box 208089, New Haven, CT 06520-8089; Vascular Biology and Therapeutics Program, Yale University, New Haven, CT; VA Connecticut Healthcare System, West Haven, CT.
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Lee T, Misra S. New Insights into Dialysis Vascular Access: Molecular Targets in Arteriovenous Fistula and Arteriovenous Graft Failure and Their Potential to Improve Vascular Access Outcomes. Clin J Am Soc Nephrol 2016; 11:1504-1512. [PMID: 27401527 PMCID: PMC4974876 DOI: 10.2215/cjn.02030216] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Vascular access dysfunction remains a major cause of morbidity and mortality in hemodialysis patients. At present there are few effective therapies for this clinical problem. The poor understanding of the pathobiology that leads to arteriovenous fistula (AVF) and graft (AVG) dysfunction remains a critical barrier to development of novel and effective therapies. However, in recent years we have made substantial progress in our understanding of the mechanisms of vascular access dysfunction. This article presents recent advances and new insights into the pathobiology of AVF and AVG dysfunction and highlights potential therapeutic targets to improve vascular access outcomes.
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Affiliation(s)
- Timmy Lee
- Department of Medicine and Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
- Veterans Affairs Medical Center, Birmingham, Alabama; and
| | - Sanjay Misra
- Vascular and Interventional Radiology Translational Laboratory, Department of Radiology, Mayo Clinic, Rochester, Minnesota
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25
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Affiliation(s)
- Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
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Field M, McGrogan D, Marie Y, Joinson M, Andujar C, Dutton M, Krishnan H, Hodson J, van Dellen D, Inston NG. Randomized clinical trial of the use of glyceryl trinitrate patches to aid arteriovenous fistula maturation. Br J Surg 2016; 103:1269-75. [PMID: 27470183 DOI: 10.1002/bjs.10217] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 03/18/2016] [Accepted: 04/25/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Arteriovenous fistulas are critical for haemodialysis, but maturation rates remain poor. Experimental and anecdotal evidence has supported the use of transdermal glyceryl trinitrate (GTN) patches. The aim of this RCT was to determine whether use of a GTN patch aids arteriovenous fistula maturation. METHODS Patients referred for arteriovenous fistula formation were eligible. The GTN or placebo patch was applied immediately after surgery and left in situ for 24 h. The primary outcome measure was the change in venous diameter at 6 weeks after fistula formation. The secondary outcome measure was clinical fistula patency at 6 weeks. RESULTS Of 200 patients recruited (533 screened), 101 were randomized to the placebo group and 99 to the GTN group. Of these, 81 and 86 respectively completed surgery, and had follow-up data available at 6 weeks. Improvements in venous diameter were similar in the two groups: mean(s.d.) increase 2·3(1·9) mm in the placebo group compared with 2·2(1·8) mm in the GTN group (P = 0·704). The fistula failure rate did not differ significantly between the two groups: 23 per cent for placebo and 28 per cent for GTN (P = 0·596). CONCLUSION GTN transdermal patches used for 24 h after surgery did not improve arteriovenous fistula maturation. REGISTRATION NUMBER NCT01685710 (http://www.clinicaltrials.gov).
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Affiliation(s)
- M Field
- Departments of Renal Transplantation and Vascular Access Surgery, Institute of Translational Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - D McGrogan
- Departments of Renal Transplantation and Vascular Access Surgery, Institute of Translational Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - Y Marie
- Departments of Renal Transplantation and Vascular Access Surgery, Institute of Translational Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - M Joinson
- Departments of Renal Research, Institute of Translational Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - C Andujar
- Departments of Renal Research, Institute of Translational Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - M Dutton
- Departments of Renal Research, Institute of Translational Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - H Krishnan
- Departments of Renal Transplantation and Vascular Access Surgery, Institute of Translational Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - J Hodson
- Department of Statistics, Institute of Translational Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - D van Dellen
- Departments of Renal Transplantation and Vascular Access Surgery, Institute of Translational Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK.,Renal and Pancreas Transplant Unit, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - N G Inston
- Departments of Renal Transplantation and Vascular Access Surgery, Institute of Translational Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
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Tanner NC, da Silva AF. Medical Adjuvant Treatment to Improve the Patency of Arteriovenous Fistulae and Grafts: A Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2016; 52:243-52. [PMID: 27289558 DOI: 10.1016/j.ejvs.2016.04.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Accepted: 04/18/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Many patients using haemodialysis for end-stage renal disease (ESRD) require arteriovenous fistulae (AVF) or grafts. Patency can be variable, and this systematic review aimed to determine the effects of adjuvant drug treatment on the patency of AVFs and grafts. METHODS The Cochrane Peripheral Vascular Diseases Group searched the Specialised Register and CENTRAL for all randomised controlled trials (RCTs) investigating the effect of active drug versus placebo on patency. The primary outcome was fistula or graft patency rate. The odds ratio (OR) was used as the measure of effect for each outcome. If several trials assessed the same adjuvant therapy then a meta-analysis was conducted using a Mantel-Haenszel model. RESULTS Fifteen trials were deemed suitable for inclusion, investigating nine drug treatments in 2,230 participants. Overall, the quality of evidence was low. Three trials compared ticlopidine (a platelet aggregation inhibitor) versus placebo and favoured active treatment (OR 0.45, 95% CI 0.25 to 0.82; p = .009). Three RCTs assessed aspirin versus placebo and did not show a statistical benefit (OR 0.40, 95% CI 0.07-2.25; p = .30). Two trials compared clopidogrel with placebo. The overall result did not favour treatment (OR 0.40, 95% CI 0.13 to 1.19; p = .10). Three trials evaluated human type-I pancreatic elastase but did not provide evidence of improved patency (OR 0.75, 95% CI 0.42-1.32; p = .31). Finally, two RCTs assessed fish oil and did not favour treatment (OR 0.24, 95% CI 0.03-1.95; p = .18). Single trials comparing dipyridamole alone, dipyridamole plus aspirin, and sulfinpyrazone against placebo favoured active treatment but a meta-analysis could not be undertaken. Finally, a single trial of warfarin versus placebo found warfarin resulted in increased complications and worse patency rates. CONCLUSION This systematic review has not demonstrated a beneficial effect for any adjuvant treatment to increase the patency of AVF or grafts in the short term, except ticlopidine which has been taken off the market.
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Affiliation(s)
- N C Tanner
- Department of Vascular Surgery, Wrexham Maelor Hospital, Wrexham LL13 7TD, UK.
| | - A F da Silva
- Department of Vascular Surgery, Wrexham Maelor Hospital, Wrexham LL13 7TD, UK
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Wong MD, Bingham K, Moss E, Warn JD, Smirnov I, Bland KS, Starcher B, Franano FN, Burke SK. Recombinant Human Elastase Treatment of Cephalic Veins. ACTA ACUST UNITED AC 2016; 5. [PMID: 27275001 DOI: 10.4172/2329-6607.1000178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Vessel injury at the time of Arteriovenous Fistula (AVF) creation may lead to neointimal hyperplasia that impairs AVF maturation. Vonapanitase, a recombinant human chymotrypsin-like elastase family member 1, is an investigational drug under development to improve AVF maturation and patency. The current studies were designed to document vonapanitase effects in human cephalic veins that are used in AVF creation. METHODS Human cephalic veins were mounted on a perfusion myograph. Vonapanitase 1.2, 4, 13.2, and 40 μg/ml or saline was applied drop wise on the vein followed by saline rinse. Vein segments were cut into rings for elastin content determination by desmosine radioimmunoassay and histology. Fluorescently-labelled vonapanitase was applied to veins and adventitial imaging was performed using laser scanning confocal microscopy. In vivo time course experiments were performed by treating rabbit jugular veins and harvesting 1 h and 4 h after vonapanitase treatment. RESULTS / CONCLUSION Vonapanitase reduced desmosine content in a dose-related manner. Histology also confirmed a dose-related reduction in elastic fiber staining. Fluorescently-labelled vonapanitase persistently localized to elastic fibers in the vein adventitia. In vivo experiments showed a reduction in desmosine content in jugular veins from 1 h to 4 h following treatment. These data suggest that vonapanitase targets elastin in elastic fibers in a dose related manner and that elastase remains in the vessel wall and has catalytic activity for at least 1 h.
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Affiliation(s)
- Marco D Wong
- Research and Development, Proteon Therapeutics, Inc. Waltham, Massachusetts, USA
| | | | | | - J Donald Warn
- University of Kansas Medical Center, Kansas City, USA
| | - Igor Smirnov
- Research and Development, Proteon Therapeutics, Inc. Waltham, Massachusetts, USA
| | - Kimberly S Bland
- Research and Development, Proteon Therapeutics, Inc. Waltham, Massachusetts, USA
| | | | - F Nicholas Franano
- Research and Development, Proteon Therapeutics, Inc. Waltham, Massachusetts, USA
| | - Steven K Burke
- Research and Development, Proteon Therapeutics, Inc. Waltham, Massachusetts, USA
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Bashar K, Conlon PJ, Kheirelseid EAH, Aherne T, Walsh SR, Leahy A. Arteriovenous fistula in dialysis patients: Factors implicated in early and late AVF maturation failure. Surgeon 2016; 14:294-300. [PMID: 26988630 DOI: 10.1016/j.surge.2016.02.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 02/09/2016] [Accepted: 02/12/2016] [Indexed: 11/25/2022]
Abstract
Increasing numbers of patients are being diagnosed with end-stage renal disease (ESRD), and the demand for on haemodialysis (HD) is rising. Arteriovenous fistulae (AVFs) remain the best conduit for adequate HD, with fewer complications associated with long-term use compared to bypass grafts and central venous catheters. However, it is known that many newly formed fistulae do not mature to provide useful HD access. The paper provides a narrative overview of factors influencing the process of AVF maturation failure.
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Affiliation(s)
- Khalid Bashar
- Department of Vascular Surgery, University Hospital Limerick, Dooradoyle, Limerick, Ireland.
| | - Peter J Conlon
- Department of Nephrology, Beaumont Hospital and Royal College of Surgeons in Ireland, Ireland
| | - Elrasheid A H Kheirelseid
- Department of Vascular Surgery, Royal College of Surgeons in Ireland, and Beaumont Hospital, Dublin 9, Ireland
| | - Thomas Aherne
- Department of Vascular Surgery, University Hospital Limerick, Dooradoyle, Limerick, Ireland
| | - Stewart R Walsh
- Department of Surgery, National University of Ireland, Galway, Ireland
| | - Austin Leahy
- Department of Vascular Surgery, Royal College of Surgeons in Ireland, and Beaumont Hospital, Dublin 9, Ireland
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Lee T, Haq NU. New Developments in Our Understanding of Neointimal Hyperplasia. Adv Chronic Kidney Dis 2015; 22:431-7. [PMID: 26524947 DOI: 10.1053/j.ackd.2015.06.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 06/26/2015] [Indexed: 12/20/2022]
Abstract
The vascular access remains the lifeline for the hemodialysis patient. The most common etiology of vascular access dysfunction is venous stenosis at the vein-artery anastomosis in arteriovenous fistula and at the vein-graft anastomosis in arteriovenous grafts (AVG). This stenotic lesion is typically characterized on histology as aggressive venous neointimal hyperplasia in both arteriovenous fistula and AVG. In recent years, we have advanced our knowledge and understanding of neointimal hyperplasia in vascular access and begun testing several novel therapies. This article will (1) review recent developments in our understanding of the pathophysiology of neointimal hyperplasia development in AVG and fistula failure, (2) discuss atypical factors leading to neointimal hyperplasia development, (3) highlight key novel therapies that have been evaluated in clinical trials, and (4) discuss future opportunities and challenges to improve our understanding of vascular access dysfunction and translate this knowledge into novel and innovative therapies.
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Tanner NC, Da Silva A. Medical adjuvant treatment to increase patency of arteriovenous fistulae and grafts. Cochrane Database Syst Rev 2015; 2015:CD002786. [PMID: 26184395 PMCID: PMC7104664 DOI: 10.1002/14651858.cd002786.pub3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND End-stage renal disease (ESRD) patients often require either the formation of an arteriovenous (AV) fistula or an AV interposition prosthetic shunt for haemodialysis. These access sites should ideally have a long life and a low rate of complications (for example thrombosis, infection, stenosis, aneurysm formation and distal limb ischaemia). Although some of the complications may be unavoidable, any adjuvant technique or medical treatment aimed at decreasing complications would be welcome. This is the second update of the review first published in 2004. OBJECTIVES To assess the effects of adjuvant drug treatment in ESRD patients on haemodialysis via autologous AV fistulae or prosthetic interposition AV shunts. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched March 2015) and CENTRAL (2015, Issue 2). SELECTION CRITERIA Randomised controlled trials (RCTs) of active drug versus placebo in people with ESRD undergoing haemodialysis via an AV fistula or prosthetic interposition AV graft. DATA COLLECTION AND ANALYSIS For this update, the two review authors (NCT, ADS) independently assessed trial quality and one review author (NCT) extracted data. Information on adverse events was collected from the trials. The primary outcome was the long-term fistula or graft patency rate. Secondary outcomes included duration of hospital stay, complications and number of related surgical interventions. MAIN RESULTS For this update, an additional six studies were deemed suitable for inclusion, making a total of 15 trials with 2230 participants. Overall the quality of the evidence was low due to short follow-up periods, heterogeneity between trials and moderate methodological quality of the studies due to incomplete reporting. Medical adjuvant treatments used in the trials were aspirin, ticlopidine, dipyridamole, dipyridamole plus aspirin, warfarin, fish oil, clopidogrel, sulphinpyrazone, and human type I pancreatic elastase (PRT-201). Where possible, the included studies were pooled into similar medical adjuvant groups for meta-analyses.All included studies reported on graft patency by measuring graft thrombosis. There was insufficient evidence to determine if there was a difference in graft patency in studies comparing aspirin versus placebo (three RCTs, 175 participants) (odds ratio (OR) 0.40, 95% confidence interval (CI) 0.07 to 2.25; P = 0.30). The meta-analysis for graft patency comparing ticlopidine versus placebo (three RCTs, 339 participants) favoured ticlopidine (OR 0.45, 95% CI 0.25 to 0.82; P = 0.009). There was insufficient evidence to determine if there was a difference in graft patency in studies comparing fish oil versus placebo (two RCTs, 220 participants; OR 0.24, 95% CI 0.03 to 1.95; P = 0.18); and studies comparing clopidogrel and placebo (two RCTs, 959 participants; OR 0.40, 95% CI 0.13 to 1.19; P = 0.10). Similarly, there was insufficient evidence to determine if there was a difference in graft patency in three studies (306 participants) comparing PRT-201 versus placebo (OR 0.75, 95% CI 0.42 to 1.32; P = 0.31); in one trial comparing the effect of dipyridamole versus placebo (42 participants; OR 0.46, 95% CI 0.11 to 1.94, P = 0.29) and dipyridamole plus aspirin versus placebo (41 participants; OR 0.64, CI 0.16 to 2.56, P = 0.52); in one trial comparing low-dose warfarin with placebo (107 participants; OR 1.76, 95% CI 0.78 to 3.99, P = 0.17); and one trial (16 participants) comparing sulphinpyrazone versus placebo (OR 0.43, 95% CI 0.03 to 5.98, P = 0.53). The single trial evaluating warfarin was terminated early because of major bleeding events in the warfarin group. Only two studies published data on the secondary outcome of related interventions (surgical or radiological); there was insufficient evidence to determine if there was a difference in related interventions between placebo and treatment groups. No studies reported on the length of hospital stay and data reporting on complications was limited and varied between studies. AUTHORS' CONCLUSIONS The meta-analyses of three studies for ticlopidine (an anti-platelet treatment), which all used the same dose of treatment but with a short follow-up of only one month, suggest ticlopidine may have a beneficial effect as an adjuvant treatment to increase the patency of AV fistulae and grafts in the short term. There was insufficient evidence to determine if there was a difference in graft patency between placebo and other treatments such as aspirin, fish oil, clopidogrel, PRT-201, dipyridamole, dipyridamole plus aspirin, warfarin, and sulphinpyrazone. However, the quality of the evidence was low due to short follow-up periods, the small number of studies for each comparison, heterogeneity between trials and moderate methodological quality of the studies due to incomplete reporting. It, therefore, appears reasonable to suggest further prospective studies be undertaken to assess the use of these anti-platelet drugs in renal patients with an arteriovenous fistula or graft.
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Affiliation(s)
- Nicola C Tanner
- Wrexham Maelor HospitalDepartment of Vascular SurgeryCroesnewydd RoadWrexhamUKLL13 7TD
| | - Anthony Da Silva
- Wrexham Maelor HospitalDepartment of Vascular SurgeryCroesnewydd RoadWrexhamUKLL13 7TD
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Optimizing outcomes in the elderly with end-stage renal disease--live long and prosper. J Vasc Access 2015; 16:439-45. [PMID: 26109536 DOI: 10.5301/jva.5000440] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2015] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The elderly form an expanding proportion of patients with chronic kidney disease and end-stage renal disease worldwide. The increased physiological frailty and functional morbidity associated with the aging process pose unique challenges when planning optimal management of an older patient needing renal replacement therapy (RRT). AIMS This position paper discusses current evidence regarding the optimal management of end-stage renal disease in the elderly with an emphasis on hemodialysis since it is the most common modality used in older patients. Further research is needed to define relevant patient-reported outcome measures for end-stage renal disease including functional assessments and psychological impacts of various forms of RRT. For those older patients who have opted for dialysis treatment, it is important to study the strategies that encourage greater uptake of home-based dialysis therapies and optimal vascular access. CONCLUSIONS The management of advanced chronic kidney disease in the elderly can be challenging but also extremely rewarding. The key issue is adopting a patient-focused and individualized approach that seeks to achieve the best outcomes based on a comprehensive holistic assessment of what is important to the patient.
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Influence of drugs on arteriovenous vascular access dysfunction. J Vasc Access 2015; 16 Suppl 9:S61-5. [PMID: 25751553 DOI: 10.5301/jva.5000365] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2015] [Indexed: 01/04/2023] Open
Abstract
Vascular access dysfunction, due to venous stenosis at the vein-artery anastomosis in arteriovenous fistulas and vein-graft anastomosis in synthetic arteriovenous grafts, is a major cause of morbidity and mortality in dialysis patients. The two overarching approaches to prevent and treat vascular access dysfunction are from systemic or local (including endovascular and perivascular) routes. However, there are currently very few effective therapies to treat vascular access dysfunction. This article will review major studies evaluating systemic, endovascular, and perivascular therapies for vascular access dysfunction. Ongoing research to evaluate novel innovations to prevent and/or manage vascular access dysfunction appears promising.
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Roy-Chaudhury P. Emerging Therapies for Chronic Kidney Disease. CHRONIC RENAL DISEASE 2015:771-780. [DOI: 10.1016/b978-0-12-411602-3.00064-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/19/2023]
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Abstract
Rationale: At physiologic pressures, elastic fibers constrain artery diameter. Local treatment of atherosclerotic arteries with PRT-201, a recombinant type I elastase, could result in fragmentation and removal of elastin fibers and increased vessel diameter. Objective: To investigate the use of PRT-201 as a treatment for human atherosclerotic arteries. Methods and Results: Arteries were harvested from donor legs amputated due to severe peripheral artery disease or from recently deceased persons who donated their bodies to science. Three- to four-centimeter artery segments were studied on a perfusion myograph to obtain baseline diameter data. After treatment with PRT-201 3.6 mg/mL or saline for 30 minutes myography was repeated. PRT-201 treatment resulted in an increase in vessel diameter across a range of transmural pressures. Average anterior tibial artery diameter increased by 0.78 ± 0.21 mm (27% ± 12%), whereas average posterior tibial artery diameter increased by 0.58 ± 0.30 mm (21% ± 11%), both P < 0.001. Elastin content as measured by desmosine radioimmunoassay was reduced by approximately 50%, P < 0.001. Conclusions: The results suggest that PRT-201 treatment of atherosclerotic peripheral arteries in patients could increase artery diameter, and thus luminal area, possibly alleviating some of the symptoms of peripheral artery disease.
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Roy-Chaudhury P, Kruska L. Future Directions for Vascular Access for Hemodialysis. Semin Dial 2014; 28:107-13. [DOI: 10.1111/sdi.12329] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Prabir Roy-Chaudhury
- Dialysis Vascular Access Research Group; Division of Nephrology; University of Cincinnati and Cincinnati VA Medical Center; Cincinnati Ohio
| | - Lindsay Kruska
- Division of Nephrology; University of North Carolina; Chapel Hill North Carolina
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Dwivedi AJ, Roy-Chaudhury P, Peden EK, Browne BJ, Ladenheim ED, Scavo VA, Gustafson PN, Wong MD, Magill M, Lindow F, Blair AT, Jaff MR, Franano FN, Burke SK. Application of human type I pancreatic elastase (PRT-201) to the venous anastomosis of arteriovenous grafts in patients with chronic kidney disease. J Vasc Access 2014; 15:376-84. [PMID: 24811601 PMCID: PMC6159820 DOI: 10.5301/jva.5000235] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2014] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To explore the safety and efficacy of PRT-201 applied to the outflow vein of a newly created arteriovenous graft (AVG). METHODS Randomized, double-blind, placebo-controlled, single-dose escalation study of PRT-201 (0.01 to 9 mg) applied to the graft-vein anastomosis and adjacent outflow vein immediately after AVG placement. The primary outcome measure was safety. The efficacy measures were intraoperative increases in outflow vein diameter and blood flow rate, primary unassisted patency, and secondary patency by dose groups (placebo, low, medium, high and All PRT-201). RESULTS A total of 89 patients were treated (28 placebo and 61 PRT-201). There were no significant differences in the proportion of placebo and PRT-201 patients reporting adverse events. Intraoperative outflow vein diameter increased 5% (p=0.14) in the placebo group compared with 13% (p=0.01), 15% (p=0.07) and 12% (p<0.001), in the low, medium and high groups, respectively. The comparison between the high and placebo groups was marginally statistically significant (p=0.06). The intraoperative blood flow did not change in the placebo group, and increased in the low, medium and high groups by 19% (p=0.34), 36% (p=0.09) and 46% (p=0.02), respectively. The low group had the longest primary unassisted and secondary patency and the fewest procedures to restore or maintain patency; however, the differences between groups were not statistically significant. CONCLUSIONS PRT-201 was well tolerated and increased AVG intraoperative outflow vein diameter and blood flow. Low dose tended to increase secondary patency and decrease the rate of procedures to restore or maintain patency. Larger studies with these doses will be necessary to confirm these results.
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Affiliation(s)
- Amit J. Dwivedi
- Department of Surgery, University of Louisville, Louisville, KY - USA
| | | | - Eric K. Peden
- Department of Cardiovascular Surgery, The Methodist Hospital, Houston, TX - USA
| | | | | | - Vincent A. Scavo
- Department of Cardiovascular and Thoracic Surgery, Indiana/Ohio Heart, Fort Wayne, IN - USA
| | | | - Marco D. Wong
- Research and Development, Proteon Therapeutics, Waltham, MA - USA
| | - Marianne Magill
- Research and Development, Proteon Therapeutics, Waltham, MA - USA
| | - Francesca Lindow
- Research and Development, Proteon Therapeutics, Waltham, MA - USA
| | - Andrew T. Blair
- Research and Development, Proteon Therapeutics, Waltham, MA - USA
| | - Michael R. Jaff
- VasCore, the Vascular Ultrasound Core Laboratory, Massachusetts General Hospital, Boston, MA - USA
| | | | - Steven K. Burke
- Research and Development, Proteon Therapeutics, Waltham, MA - USA
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Affiliation(s)
- Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
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Human type I pancreatic elastase treatment of arteriovenous fistulas in patients with chronic kidney disease. J Vasc Surg 2014; 60:454-461.e1. [DOI: 10.1016/j.jvs.2014.02.037] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 02/04/2014] [Indexed: 11/17/2022]
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Terry CM, Dember LM. Novel therapies for hemodialysis vascular access dysfunction: myth or reality? Clin J Am Soc Nephrol 2013; 8:2202-12. [PMID: 24235283 DOI: 10.2215/cjn.07360713] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hemodialysis vascular access dysfunction is a major source of morbidity for patients with ESRD. Development of effective approaches to prevent and treat vascular access failure requires an understanding of the underlying mechanisms, suitable models for preclinical testing, systems for targeted delivery of interventions to maximize efficacy and minimize toxicity, and rigorous clinical trials that use appropriate outcome measures. This article reviews the substantial progress and ongoing challenges in developing novel treatments for arteriovenous vascular access failure and focuses on localized rather than systemic interventions.
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Affiliation(s)
- Christi M Terry
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah, †Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Lee T. Novel paradigms for dialysis vascular access: downstream vascular biology--is there a final common pathway? Clin J Am Soc Nephrol 2013; 8:2194-201. [PMID: 23990166 DOI: 10.2215/cjn.03490413] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Vascular access dysfunction is a major cause of morbidity and mortality in hemodialysis patients. The most common cause of vascular access dysfunction is venous stenosis from neointimal hyperplasia within the perianastomotic region of an arteriovenous fistula and at the graft-vein anastomosis of an arteriovenous graft. There have been few, if any, effective treatments for vascular access dysfunction because of the limited understanding of the pathophysiology of venous neointimal hyperplasia formation. This review will (1) describe the histopathologic features of hemodialysis access stenosis; (2) discuss novel concepts in the pathogenesis of neointimal hyperplasia development, focusing on downstream vascular biology; (3) highlight future novel therapies for treating downstream biology; and (4) discuss future research areas to improve our understanding of downstream biology and neointimal hyperplasia development.
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Affiliation(s)
- Timmy Lee
- Department of Internal Medicine, Division of Nephrology and Hypertension, University of Cincinnati, Cincinatti, Ohio;, †Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio;, ‡Dialysis Vascular Access Research Group, Cincinnati, Ohio, §Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
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Riella MC, Roy-Chaudhury P. Vascular access in haemodialysis: strengthening the Achilles' heel. Nat Rev Nephrol 2013; 9:348-57. [DOI: 10.1038/nrneph.2013.76] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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