Drug-Eluting Balloon for the Treatment of Failing Hemodialytic Radiocephalic Arteriovenous Fistulas: Our Experience in the Treatment of Juxta-Anastomotic Stenoses

Angioplasty for dysfunctional arteriovenous fistulas: A meta-analysis of recent randomized controlled trials compared paclitaxel-coated balloon versus conventional balloon angioplasty

BACKGROUND

Stenosis in arteriovenous fistulas (AVF) due to neointimal hyperplasia is one of the most common causes of hemodialysis vascular access dysfunction. Treating patients with dysfunctional AVF with drug-coated balloon (DCB) angioplasty may potentially improve outcomes.

OBJECTIVES

This systematic review aimed to compare the effectiveness and safety of DCB angioplasty versus conventional balloon angioplasty by pooling evidence from the most recent randomized controlled trials.

METHODS

We conducted a comprehensive literature search in the Web of Science, Embase, and Cochrane central databases. Two independent researchers screened the article, extracted interest, and evaluated included studies for risk of bias. Pooled estimation was conducted in terms of 6-month target-lesion primary patency (TLPP) and target-lesion reintervention (TLR), as well as other outcomes.

RESULTS

Results were expressed with odds ratio (OR) and 95% confidence interval (CI). A total of five RCTs were identified and included in the meta-analyses, with 1107 participants. DCB has a trend of a higher rate of TLPP (OR 1.79, 95% CI 0.66-4.90, p = 0.181) and a significantly lower rate of TLR (0.52, 95% CI 0.29-0.92, p = 0.034), as compared to conventional balloon angioplasty. No difference in the 6-month access circuit primary patency and reinvention was observed between the two groups.

CONCLUSION

DCB may be an alternative treatment of dysfunctional AVF given a trend of a higher rate of TLPP and a significantly lower rate of TLR than conventional balloon angioplasty within 6 months after the indexed procedure. Moreover, DCB was non-inferior to conventional balloon angioplasty in terms of safety. Considering variations in the DCB technique, further studies are warranted for a standardized process.

Contemporary review of management techniques for cephalic arch stenosis in hemodialysis

The type of hemodialysis access and its preservation impact the quality of life and survival of patients undergoing hemodialysis. Vascular access complications are among the top causes of morbidity, hospitalization, and catheter use, with significant economic burden. Poor maturation and stenosis continue to be key impediments to upper arm arteriovenous fistula feasibility. Cephalic arch is a common location for vascular access dysfunction due to its distinctive anatomy, complex valves, and biochemical alterations attributable to renal failure. Understanding cephalic arch stenosis is critical due to its high prevalence and treatment failure. The appropriate management option is highly debatable and mostly dependent on patient characteristics and interventionist's preference. Current options include, percutaneous transluminal balloon angioplasty, stent grafts, bare metal stents, cutting balloon angioplasty, endovascular banding, and surgical procedures. This article discusses the etiologies of cephalic arch stenosis as well as currents trends in management including endovascular and surgical options.

Central vein stenosis in hemodialysis vascular access: clinical manifestations and contemporary management strategies

Central venous stenosis is a significant and frequently encountered problem in managing hemodialysis (HD) patients. Venous hypertension, often accompanied by severe symptoms, undermines the integrity of the hemodialysis access circuit. In central venous stenosis, dialysis through an arteriovenous fistula is usually inefficient, with high recirculation rates and prolonged bleeding after dialysis. Central vein stenosis is a known complication of indwelling intravascular and cardiac devices, such as peripherally inserted central catheters, long-term cuffed hemodialysis catheters, and pacemaker wires. Hence, preventing this challenging condition requires minimization of central venous catheter use. Endovascular interventions are the primary approach for treating central vein stenosis. Percutaneous angioplasty and stent placement may reestablish vascular function in cases of elastic and recurrent lesions. Currently, there is no consensus on the optimal treatment, as existing management approaches have a wide range of patency rates.

The role of stents in hemodialysis vascular access

Vascular access is the Achilles' heel of dialysis therapy among patient with end stage kidney disease. The development of neointimal hyperplasia and subsequent stenosis is common in vascular access and is associated with significant morbidity. Percutaneous transluminal angioplasty using balloon inflation was the standard therapy of these lesions. However, the balloon-based approaches were associated with poor vascular access patency rate necessitating new inventions. It is within this context that different types of stents were developed in order to improve the overall dialysis vascular access functionality. In this article, we review the available literature regarding the use of stents in treating dialysis vascular access stenotic lesions. Further, we review the major clinical trials of stent use in different anatomic locations and in different clinical scenarios.

Swing segment stenosis: An unresolved challenge

The native arteriovenous fistula is considered the gold standard among all dialysis access options. Compared with alternatives such as grafts and central venous catheters, their use is associated with a lower risk of infective and thrombotic complications. This leads to better patient outcomes and reduced healthcare-associated costs. Recognizing these advantages, there is a global drive to increase the creation and use of such fistulas in hemodialysis patients. Swing segment stenosis is a common problem encountered with the creation and use of these fistulas that can hurt their maturation and longevity. A "swing segment" in an arteriovenous fistula is defined as a segment of vein that pursues a sharp, curved course. Due to poorly understood reasons, these swing segments tend to develop stenotic lesions that are extremely challenging to treat. This review aims to provide an overview of the pathophysiology, incidence, management, and prevention of these swing segment lesions. We believe that such knowledge will be useful for clinicians who deal with dialysis access creation and maintenance.

Drug-eluting balloon (DEB) versus plain old balloon angioplasty (POBA) in the treatment of failing dialysis access: A prospective randomized trial

Objective

To compare the efficacy of angioplasty using drug-eluting balloons (DEB) compared with plain old balloon angioplasty (POBA) to reduce the rate of restenosis.

Methods

This prospective, single-centre, single-blinded, 1:1 randomized, clinical trial enrolled patients that had primary or restenotic lesions in native upper extremity arteriovenous (AV) fistulas or at the graft-venous anastomosis. Patients were randomized to angioplasty with a POBA or a DEB. The primary effectiveness endpoints were freedom from target lesion revascularization (TLR) and functional status of access circuit at 12 months.

Results

A total of 42 (28 male, 14 female; age range, 42–83 years) patients were enrolled. Patients were followed for 12 months. No significant differences were detected between the POBA and DEB groups regarding total number of TLR procedures (31 versus 36, respectively), freedom from TLR (3 versus 4, respectively) and functional status of the access circuit at 12 months (14 of 20 patients [70%] versus 17 of 22 patients [77%], respectively).

Conclusion

This clinical trial did not demonstrate any significant differences between DEB angioplasty and standard balloon angioplasty when treating dysfunctional haemodialysis access.

Drug-Coated Balloons for the Dysfunctional Vascular Access: An Evidence-Based Road Map to Treatment and the Existing Obstacles

An underlying stenosis within the venous limb of a hemodialysis access circuit is the main etiology for graft and fistula dysfunction as well as other symptoms such as arm, breast, and neck swelling. Treatment options for both peripheral and central venous stenoses include plain old balloon angioplasty, angioplasty with drug-coated balloons, and stenting. This article discusses the current evidence for the use of drug-coated balloon angioplasty in this patient population.

A prospective randomized feasibility trial comparing angiography and angiography with intravascular ultrasound for treatment of hemodialysis access failures

OBJECTIVE

Hemodialysis accesses suffer from limited primary patency requiring frequent interventions, revisions, or even abandonment. Prolongation of access life and usability with minimization of these adverse events is paramount. Endovascular methods are established first-line interventions for failing arteriovenous access and treatment of venous outflow stenoses. The Primary goal of this feasibility study was to evaluate intravascular ultrasound (IVUS) during interventional treatments on outcomes in those undergoing angiography for failing hemodialysis access. Secondary goals were to determine differences between IVUS and angiography on vessel and lesion characteristics and impact on treatment.

METHODS

In this prospective, randomized controlled trial, patients scheduled for angiography to evaluate and treat a failing hemodialysis access were randomized to use of angiography (DSA) alone or angiography plus IVUS (DSA + IVUS). Patients were treated by a standardized protocol and seen in follow-up at 2 weeks, and every 3 months for 2 years or until a study endpoint was reached. Measurement of vessel diameters, % stenosis, lesion length, and study endpoints (AV access thrombosis, re-intervention, or surgical revision) were recorded.

RESULTS

A total of 55 subjects were enrolled, 27 in the DSA cohort and 28 in the DSA + IVUS cohort. There were 41 treated lesions in each group. Freedom from the composite endpoint of AV access thrombosis or re-intervention was 46.3% in the DSA cohort and 61.0% in the DSA + IVUS cohort (p = 0.27). Diameter measurements matched between the two imaging modalities only 9 times out of 41 total comparison measures. In pre-treatment lesions with >80% stenosis, IVUS had a greater tendency than DSA to underestimate the severity of stenosis, whereas in pre-treatment lesions with 50-80% stenosis, DSA was more likely than IVUS to underestimate the severity of stenosis. Post-treatment % stenosis had mean difference of -7.5% between DSA versus DSA + IVUS cohorts. In five lesions with <30% stenosis measured by angiogram, IVUS led to treatment escalation.

CONCLUSION

In the interventional treatment of failing angioaccess, IVUS and angiography differ in the vast majority of cases in measurement of vessel diameter. A significant number of patients were found to have suboptimal therapeutic response by IVUS only, which led to an escalation in treatment, and in over one-third of cases, the IVUS results led to a change in treatment plan. The improved patency rates in the IVUS group was not statistically significant in this small population but should be further investigated in a larger trial.

Efficacy and Safety of Paclitaxel-Coated Balloon Angioplasty for Dysfunctional Arteriovenous Fistulas: A Multicenter Randomized Controlled Trial

RATIONALE & OBJECTIVE

Previous studies have illustrated the potential superiority of drug-coated balloons (DCBs) in maintaining patency after initial angioplasty for arteriovenous fistula (AVF) dysfunction due to stenosis. Our trial evaluated the efficacy and safety of DCBs for preventing fistula restenosis in Chinese hemodialysis patients.

STUDY DESIGN

Multicenter, prospective, randomized, open-label, blinded end point, controlled trial.

SETTINGS & PARTICIPANTS

A total of 161 hemodialysis patients with fistula dysfunction from 10 centers in China.

INTERVENTION

Participants were randomized 1:1 to treatment with initial dilation followed by DCB angioplasty or conventional high-pressure balloon (HPB) angioplasty.

OUTCOMES

The primary end point was target lesion primary patency defined as the target lesion intervention-free survival in conjunction with an ultrasonography-measured peak systolic velocity ratio (PSVR) ≤2.0 at 6 months. The secondary end points included 1) device, technical, clinical, and procedural success; 2) major adverse events; 3) degree of target lesion stenosis at 6 months; and 4) clinically driven target lesion and target shunt revascularization within 12 months.

RESULTS

The percentage with target lesion primary patency as defined by a PSVR ≤2.0 was higher in the DCB group than in the control group (65% vs 37%, respectively; rate difference, 28% [95% CI, 13%-43%]; P <0.001) at 6 months. The target lesion and target shunt intervention-free survival of the DCB group were not superior to those of the control group at 6 months (P = 0.3 and P = 0.2, respectively) but were superior at 12 months (target lesion intervention-free survival: 73% for DCB vs 58% for control [P = 0.04]; target shunt intervention-free survival: 73% for DCB vs 57% for control [P = 0.04]). The average degree of target lesion stenoses at 6 months was not significantly different between the 2 groups (44% ± 16% for DCB vs 49% ± 18% for control; P = 0.09). There were no significant differences in major adverse events or in device, technical, clinical, or procedural success rates between the groups.

LIMITATIONS

Small sample size; short follow-up period; procedural differences between the 2 groups such as unequal inflation times and balloon lengths.

CONCLUSIONS

Compared to conventional HPB angioplasty, DCB treatment achieved superior primary patency defined using PSVR measured at 6 months and superior intervention-free survival of both the target lesion and the target shunt at 12 months without evidence of greater adverse events.

FUNDING

Funded by ZhuHai Cardionovum Medical Device Co., Ltd.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov with study number NCT02962141.

Randomized Controlled Trial for Paclitaxel-coated Balloon versus Plain Balloon Angioplasty in Dysfunctional Hemodialysis Vascular Access: 12-month Outcome from a Nonsponsored Trial

BACKGROUND

Plain balloon angioplasty is regarded as the mainstay of treatment for failing vascular access with high success rate, but the poor treatment durability creates significant workload and increases patient morbidity. The study aims to compare target lesion primary patency rate at 12 months between paclitaxel-coated balloon (DCB) versus plain old balloon angioplasty (POBA) for treatment of dysfunctional vascular access.

METHODS

This nonsponsored-randomized trial enrolled 40 patients with dysfunctional dialysis access at a single center. Patients were randomized into In.Pact Admiral Paclitaxel DCB or POBA after lesion crossing regardless of lesion type. Patients are followed up under surveillance protocol. Patients, hemodialysis staff, and sonographer are blinded to the treatment arms. Twelve-month primary patency rate in both arms are evaluated.

RESULTS

40 patients were recruited since June 2016 and were allocated to the DCB or POBA group. The mean age is 58 and 57 years with comparable demographic parameters. The locations of target lesion were comparable in both groups (juxta and arteriovenous anastomosis, cannulation site, and fistula/graft), with similar mean target lesion stenosis 69.8 +/- 15.8% for DCB and 69.5 +/- 13.6% for POBA (P = 0.95), and the lesion length for DCB is 45.8 +/- 38.4 mm and 50.2 +/- 33.5 mm for POBA (P = 0.70). Patients in DCB performed significantly better in terms of primary patency at 6 months 85% versus 55% (P = 0.007). The superiority in primary patency in DCB group exists at 12 months 65% versus 30% (P = 0.007).

CONCLUSIONS

Paclitaxel balloon angioplasty approach provides significant better primary patency in dysfunctional arteriovenous access at 12 months in our nonsponsored-randomized trial.

Paclitaxel-Coated Balloon versus Plain Balloon Angioplasty for Dysfunctional Autogenous Radiocephalic Arteriovenous Fistulas: A Prospective Randomized Controlled Trial

Objective

To report the mid-term results of a single-center randomized controlled trial comparing drug-coated balloon angioplasty (DBA) and plain balloon angioplasty (PBA) for the treatment of dysfunctional radiocephalic arteriovenous fistulas (RCAVFs).

Materials and Methods

In this prospective study, 39 patients (mean age, 62.2 years; 21 males, 18 females) with RCAVFs failing due to juxta-anastomotic stenosis were randomly assigned to undergo either both DBA and PBA (n = 20, DBA group) or PBA alone (n = 19, PBA group) between June 2016 and June 2018. Primary endpoints were technical and clinical success and target lesion primary patency (TLPP); secondary outcomes were target lesion secondary patency (TLSP) and complication rates. Statistical analysis was performed using the Kaplan-Meier product limit estimator.

Results

Demographic data and baseline clinical characteristics were comparable between the groups. Technical and clinical success rates were 100% in both groups. There was no significant difference between the groups in the mean duration of TLPP (DBA group: 26.7 ± 3.6 months; PBA group: 27.0 ± 3.8 months; p = 0.902) and TLSP (DBA group: 37.3 ± 2.6 months; PBA group: 40.4 ± 1.5 months; p = 0.585). No procedural or post-procedural complications were identified.

Conclusion

Paclitaxel-coated balloon use did not significantly improve TLPP or TLSP in the treatment of juxta-anastomotic stenosis of dysfunctional RCAVFs.

Paclitaxel coated-balloon (PCB) versus standard plain old balloon (POB) fistuloplasty for failing dialysis access

INTRODUCTION

This study aimed to evaluate the safety and efficacy of paclitaxel-coated balloon compared with conventional plain balloon for the treatment of failing native dialysis access.

MATERIALS AND METHODS

This prospective study included 60 patients presenting to the Kasr Alainy Hospitals and Aseer Central Hospital in the period from September 2015 to December 2017 with failing native vascular access. Dilatation with a plain balloon was done in 30 patients (group I) and with a paclitaxel-coated balloon in 30 patients (group II) with either stenosis or occlusion. The majority were outflow lesions, with 20 (66.7 %) patients in group I and 21 (70%) patients in group II. Mean balloon diameter was 7.1mm (± 1.5mm) compared with 6.5mm (± 1.2mm) and length 66mm (± 19.1mm) compared with 54.6mm (± 15.7mm), respectively. Safety endpoint was reported as 30 day's freedom from procedure-related major complications and mortality. Procedural technical success was defined as a residual diameter 30% or less for treated lesions. Target lesion primary patency, circuit primary patency and secondary patency were reported at 3, 6 and 12 months.

RESULTS

There were no 30-day procedure-related major complications or mortality in either group. Procedural technical success of 100% was achieved in both groups. Target lesion primary patency, circuit primary patency and secondary patency in group II were better than in group I, especially at 12 months (90% vs 66.7%, 83.3% vs 60% and 96.7% vs 93.3%, respectively). There was a statistically significant difference in target lesion primary patency (p = 0.029) in patients who were treated with paclitaxel-coated balloon angioplasties.

CONCLUSION

The paclitaxel-coated balloon proved to be safe and effective, and improved the patency of failing vascular access. Results are comparable with previous studies.

Paclitaxel drug-coated balloon angioplasty for the treatment of failing arteriovenous fistulas: a single-center experience

Objectives: To report our experience of angioplasty with Lutonix (Bard Peripheral Vascular, Inc., Tempe, AZ) drug-coated balloon (DCB) for the treatment of failing arteriovenous fistulas (AVF).Materials and methods: Retrospective, single-center analysis consisting of 14 patients treated with Lutonix paclitaxel DCBs in the period from July 2015 through April 2017. We analyzed technical success, clinical success, primary patency of the target lesion, primary patency of the dialysis circuit, and the rate of complications. Regular follow-up of AVF patency was realized by clinical examination and duplex ultrasonography. The Kaplan-Meier survival method was applied to determine the cumulative primary patency of the target lesion and the dialysis circuit.Results: Technical success was 100% and clinical success 92.9%. There were no major or minor complications. Cumulative target lesion primary patency after DCB was 69.2% at 6 months and 31.6% at 12 months. Cumulative vascular circuit primary patency was 61.5% at 6 months and 31.6% at 12 months.Conclusion: Compared to results reported in literature with plain old balloon angioplasty (POBA), Lutonix paclitaxel DCB angioplasty proved a short-term patency benefit in treatment of dialysis AVF stenosis.

A retrospective comparison analysis of results of drug-coated balloon versus plain balloon angioplasty in treatment of juxta-anastomotic de novo stenosis of radiocephalic arteriovenous fistulas

BACKGROUND

Juxta-anastomotic stenosis is a common issue of arteriovenous fistulas. We aimed to evaluate the results of percutaneous transluminal angioplasty with drug-coated balloon versus plain balloon for the treatment of juxta-anastomotic stenoses of mature but failing distal radiocephalic arteriovenous fistulas.

METHODS

A total of 80 patients with a juxta-anastomotic stenosis of distal radiocephalic arteriovenous fistula in our clinic between January 2016 and September 2017 were retrospectively analyzed. Patients were divided into two groups according to the type of treatment as drug-coated balloon - percutaneous transluminal angioplasty (n = 44) and plain balloon - percutaneous transluminal angioplasty (n = 43). Intra- and post-procedural data were recorded. Target lesion primary patency rate was evaluated at 6 and 12 months. Of all patients, 48 were females and 39 were males with a mean age of 56.3 ± 10.4 (range, 24-75) years. Both groups had mature fistulas, and the mean age of fistula was 11.3 ± 9.1 months in the drug-coated balloon - percutaneous transluminal angioplasty group and 10.3 ± 8.8 months in the plain balloon - percutaneous transluminal angioplasty group (p = 0.24).

RESULTS

There was no significant difference in the target lesion stenosis rate and the median lesion length between the groups. Technical and clinical success were achieved in both groups. Target lesion primary patency was similar at 6 months between the two groups (93.1% vs 81.3%, respectively; p = 0.14) but significantly higher for the drug-coated balloon - percutaneous transluminal angioplasty group at 12 months (81.8% vs 51.1%, respectively; p = 0.01).

CONCLUSION

Our study results suggest that the use of drug-coated balloon combined with percutaneous transluminal angioplasty is an effective treatment for juxta-anastomotic stenoses of mature but failing distal radiocephalic arteriovenous fistulas with significantly improved target lesion primary patency rates and reduced need for juxta-anastomotic reinterventions.

Drug-coated balloon angioplasty in failing haemodialysis arteriovenous shunts: 12-month outcomes in 200 patients from the Aperto Italian registry

Background:

We evaluated the safety and technical and clinical outcomes of angioplasty with a drug-coated balloon for the management of venous stenosis in arteriovenous grafts and arteriovenous fistulas in patients undergoing haemodialysis.

Methods:

Data were obtained from an ongoing prospective, non-randomised registry conducted at three Italian centres. Patients were treated with a drug-coated balloon according to standard procedures in each participating centre. Evaluation was by colour Doppler imaging every 3 months. The primary end-point was primary assisted patency. The secondary end-point was the rate of assisted patency of the vascular access.

Results:

A total of 311 angioplasty procedures in 200 patients, (60.4% male), were analysed. The procedural success rate was 100%. A total of 192 treatments of restenosis were necessary in 81 patients during average 21 ± 8 months follow-up. Kaplan–Meier estimates indicated that 88.0%, 64.2% and 40.6% of treated lesions were free from restenosis at 6, 12 and 24 months, respectively. Including multiple angioplasty, circuit patency rates were 99.2%, 92.5% and 84.8% at 6, 12 and 24 months, respectively. Primary patency rates were highest in shunts treated de novo with drug-coated balloons. Risk of restenosis was associated with circuit age (p = 0.017), history of treatment with conventional angioplasty (p < 0.001) and the kind of balloon used during pre-dilation (p = 0.001).

Conclusion:

The results suggest that favourable long-term patency rates can be achieved with the drug-coated balloon in a varied population of patients with failing haemodialysis arteriovenous shunts treated under conditions of actual care.

Recent developments in endovascular interventions to sustain vascular access patency in haemodialysis patients

There is amassed evidence regarding the use of endovascular procedures for the treatment of vascular access stenosis and thrombosis. A review was conducted based on available randomized trials, cohort studies and retrospective analyses published after 2000 on endovascular treatment of dysfunctional and thrombosed vascular access, with an aim to illustrate the available device and procedural options. The use of paclitaxel-coated balloons, cutting balloons and covered stents is described in the field of vascular access stenosis. The broad spectrum of available devices and endovascular declotting procedures ranging from thrombolysis to thrombectomy is also discussed. Overall, in this review we demonstrate the increasing role of endovascular procedures in vascular access treatment and the improved patency outcomes provided by the implementation of novel endovascular devices. Moreover, the improvement of post-intervention primary patency rates after endovascular declotting procedures and the shift to more thrombectomy-dependent procedures over time is also highlighted. In conclusion, endovascular treatment of dialysis access stenosis and thrombosis has an established role, owing to the implementation of sophisticated devices, allowing, when needed, the simultaneous treatment of thrombosis and the underlying stenosis.

Multicentre, randomised, blinded, control trial of drug-eluting balloon vs Sham in recurrent native dialysis fistula stenoses

Background:

Endovascular treatment of autogenous arteriovenous haemodialysis fistula stenosis has high reintervention rates. We investigate the effect of drug-eluting balloons in the treatment of recurrent haemodialysis fistula stenosis.

Methods:

This is a randomised, controlled, investigator-initiated and run, prospective, blinded, multicentre trial. Patients with recurrent autogenous arteriovenous haemodialysis fistula stenosis received standard endovascular treatment plus drug-eluting balloon or standard endovascular treatment plus uncoated balloon (Sham). Primary endpoint was late lumen loss in trial area on ultrasound at 6 weeks, 3, 6 and 12 months. Secondary endpoints were freedom from reintervention to the Index Trial Area and decline in fistula flow (Qa). Interim analysis was performed at 6 months (unblinded due to timeliness).

Results:

Patients with 132 recurrent stenoses (48% in bare Nitinol stents) were randomised with 70 receiving drug-eluting balloon and 62 Sham. At 6 months, decline in late lumen loss was 0.23 ± 0.03 mm/month for Sham and 0.045 ± 0.03 mm/month for drug-eluting balloon arm, a significant difference (0.18 mm, p = 0.0002). At 12 months, this difference persisted at 0.12 mm (p = 0.0003). At 6 months, significant difference in late lumen loss for instent restenoses (p = 0.0004) was observed, with non-significant difference for unstented restenoses (p = 0.065). Mean time for freedom from reintervention was 10.14 months for Sham versus 42.39 months for drug-eluting balloon (p = 0.001). The same was shown for instent (p = 0.014) and unstented (p = 0.029) restenoses. Qa decline rate at 6 months was 36.89 mL/min/month (Sham) and 0.41 mL/min (drug-eluting balloon). The difference was significant (36.48 mL/min; p = 0.02) and persisted to 12 months (p = 0.44).

Conclusion:

Paclitaxel drug-eluting balloon significantly delays restenosis after angioplasty for recurrent autogenous arteriovenous haemodialysis fistula stenosis, persisting to 12 months. Drug-eluting balloon significantly increases freedom from reintervention at 12 months with these effects true in stented and unstented fistulas.

Drug-Coated Versus Plain Balloon Angioplasty In Arteriovenous Fistulas: A Randomized, Controlled Study With 1-Year Follow-Up (The Drecorest Ii-Study)

Background and Aims:

Stenosis due to intimal hyperplasia and restenosis after initially successful percutaneous angioplasty are common reasons for failing arteriovenous fistulas. The aim of this study was to evaluate the effect of drug-coated balloons in the treatment of arteriovenous fistula stenosis.

Design:

Single-center, parallel group, randomized controlled trial. Block randomized by sealed envelope 1:1.

Materials and Methods:

A total of 39 patients with primary or recurrent stenosis in a failing native arteriovenous fistulas were randomized to drug-coated balloon (n = 19) or standard balloon angioplasty (n = 20). Follow-up was 1 year. Primary outcome measure was target lesion revascularization.

Results:

In all, 36 stenoses were analyzed; three patients were excluded due to technical failure after randomization. A total of 88.9% (16/18) in the drug-coated balloon group was revascularized or occluded within 1 year, compared to 22.2% (4/18) of the stenoses in the balloon angioplasty group (relative risk for drug-coated balloon 7.09). Mean time-to- target lesion revascularization was 110 and 193 days after the drug-coated balloon and balloon angioplasty, respectively (p = 0.06).

Conclusions:

With 1-year follow-up, the target lesion revascularization-free survival after drug-coated balloon-treatment was clearly worse. The reason for this remains unknown, but it may be due to differences in the biological response to paclitaxel in the venous arteriovenous fistula-wall compared to its antiproliferative effect in the arterial wall after drug-coated balloon treatment of atherosclerotic occlusive lesions. Trial registration: ClinicalTrials.gov NCT03036241

Treatment of juxta-anastomotic stenoses for failing distal radiocephalic arteriovenous fistulas: Drug-coated balloons versus angioplasty

The aim of our study is to report the results of two types (type A, type B) paclitaxel drug-coated balloon compared with standard percutaneous transluminal angioplasty in the treatment of juxta-anastomotic stenoses of mature but failing distal radiocephalic hemodialysis arteriovenous fistulas. Two groups of 26 and 44 patients treated with two different drug-coated balloon are compared with a control group of 86 treated with standard percutaneous transluminal angioplasty. A color Doppler ultrasound was performed to evaluate stenosis and for treatment planning. We assess primary patency, defined as the absence of dysfunction of the arteriovenous fistulas, patent lesion or residual stenosis < 30% and no need for further reintervention of target lesion. Primary patency and secondary patency are evaluated after 12 months with color Doppler ultrasound for the whole arteriovenous fistulas, defined as absolute (absolute primary patency, absolute secondary patency) and target lesion. Postprocedural technical and clinical success was 100%. After 12 months, absolute primary patency is 81.8% for type A, 84.1% type B, and 54.7% for standard percutaneous transluminal angioplasty; target lesion primary patency is 92% type A, 86.4% type B, and 62.8% standard percutaneous transluminal angioplasty; absolute secondary patency is 95.4% type A, 95.5% type B, and 80.7% standard percutaneous transluminal angioplasty; target lesion secondary patency is 100% type A, 97.7% type B, and 80.7% standard percutaneous transluminal angioplasty. All the patients treated with drug-coated balloon (type A + type B) have an absolute primary patency of 83.3%, a target lesion primary patency of 87.9%, an absolute secondary patency of 95.5%, and a target lesion secondary patency of 98.4%. Our study confirms that the use of drug-coated balloon, indiscriminately among different brands, improves primary patency with statistically significant difference in comparison with standard percutaneous transluminal angioplasty and decreases reintervention of target lesion in juxta-anastomotic stenoses of failing distal arteriovenous fistulas maintaining the radiocephalic fistula as long as possible.

Near-Infrared Fluorescence Imaging of Matrix Metalloproteinase 2 Activity as a Biomarker of Vascular Remodeling in Hemodialysis Access

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.

Comparison between open and pharmacomechanical repair of acutely thrombosed arteriovenous hemodialysis fistulae within a decade

INTRODUCTION

Different declotting techniques are available for acutely thrombosed arteriovenous hemodialysis fistulae (AVF). The aim of this single-center study was to compare immediate and follow-up results between surgical repair and a modified interventional lyse-and-wait technique characterized by prolonged local reaction times of recombinant tissue-plasminogen activator (rtPA).

MATERIALS AND METHODS

We retrospectively analyzed medical records of 110 consecutively treated patients between the years 2003 and 2013. All patients were on hemodialysis (HD) and suffered from an acutely thrombosed AVF. The treatment standards changed in the course of time, wherefore we compared 2 groups: the open repair (OR) (N = 50) and the endovascular repair (ER) group (N = 60).

FINDINGS

We found no significant differences in success rates (OR 92%/ER 96.7%; P = 0.28), immediate failures (IFs) (OR 8%/ER 10%; P = 0.71), and temporary catheter placements (TCPs) (OR 10%/ER 6.7%; P = 0.52). Furthermore, there were no differences in cumulative primary patency rates (P = 0.42) and secondary patency rates (P = 0.97).The infection rate was significantly increased after OR (8%) compared to ER (0%); P = 0.026. The hospital stay in days was shorter after ER (5.2 ±2.8) vs. OR (9.0 ± 3.5); P < 0.001.

CONCLUSION

The modified lyse-and-wait technique with prolonged local reaction times is a successful alternative to surgical repair for acutely thrombosed AVF. Clear benefits are less infections and significant shorter hospital stays after ER. However, OR remains the preferred treatment for aneurysms and anastomotic stenoses.

A Review of Percutaneous Transluminal Angioplasty in Hemodialysis Fistula

The number of patients in dialysis increases every year. In this review, we will evaluate the role of percutaneous transluminal angioplasty (PTA) according to patency of arteriovenous fistula and grafts. The main indication of PΤΑ is stenosis > 50% or obstruction of the vascular lumen of an arteriovenous fistula and graft. It is usually performed under local anesthesia. The infection rate is as low as the number of complications. Fistula can be used in dialysis in the same day without the need for a central venous catheter. Primary patency is >50% in the first year while primary assisted patency is 80-90% in the same time period. Repeated PTA is as durable as the primary PTA. An early PTA carries a risk of new interventions. Cutting balloon can be used as a second-line method. Stents and covered stents are kept for the management of complications and central outflow venous stenosis. PTA is the treatment of choice for stenosis or obstruction of dialysis fistulas. Repeated PTA may be needed for better patency. Drug eluting balloon may become the future in PTA of dialysis fistula, but more trials are needed.

Impact of Lesion Morphology on Durability After Angioplasty of Failed Arteriovenous Fistulas in Hemodialysis Patients

PURPOSE

To investigate if morphological patterns of arteriovenous fistula (AVF) venous lesions affect primary patency after percutaneous transluminal angioplasty (PTA).

METHODS

From July 2014 to June 2015, 262 patients underwent PTA for failed AVFs. A total of 104 patients were excluded owing to (1) calcification or AVF occlusion precluding ultrasound examination, (2) central venous or arterial lesions, and (3) no follow-up, leaving 158 patients (mean age 71±12; 96 men) for analysis. More than half of the patients had one or more previous PTAs for the failed AVF. Prior to PTA the stenotic lesions were assessed using ultrasonography to determine stenotic patterns at the minimum lumen area site and to evaluate the flow volume in the brachial artery. Three stenotic patterns were identified: intimal hyperplasia (IH) stenosis (n=110), shrinking lumen stenosis (n=32), and venous valve-related stenosis (n=16). The main outcome measure was primary patency after PTA estimated using Kaplan-Meier analysis. Predictors for loss of primary patency were determined using a multivariate Cox proportional hazards model; the results are presented as the adjusted hazard ratio (HR) and 95% confidence interval (CI).

RESULTS

Median follow-up after PTA was 6.3 months (interquartile range 3.3, 10.5). The 6-month primary patency estimates were 56%±5% in the IH group, 40±9% in the shrinking lumen group, and 100% in the valve stenosis group (IH vs shrinking, p=0.013; IH vs valve, p=0.003). In multivariate analysis, shrinking lumen morphology had a negative impact on primary patency (HR 2.05, 95% CI 1.25 to 3.36, p=0.005), while venous valve-related stenosis had a positive impact (HR 0.19, 95% CI 0.04 to 0.79, p=0.023). Flow volume (10-mL/min increments; HR 0.97, 95% CI 0.96 to 0.99, p=0.004) and history of PTA (HR 1.66, 95% CI 1.06 to 2.60, p=0.029) were also independently associated with primary patency after PTA.

CONCLUSION

The patterns of AVF stenosis as determined by ultrasound can affect the outcome of treatment with balloon dilation.

A Single-Center Retrospective Analysis of the Efficacy of a New Balloon Catheter in Autogenous Arteriovenous Fistula Dysfunction Resistant to Conventional Balloon Angioplasty

PURPOSE

The purpose of the study was to present a new alternative balloon catheter option for autogenous arteriovenous fistula (AVF) dysfunction with a stiff constriction resistant to conventional balloon angioplasty.

METHODS

Our first series of 51 patients with autogenous AVF dysfunction who were simultaneously treated with VascuTrak™ balloon catheter, following failed conventional balloon therapy (failure was defined as residual stenosis of >30%), were retrospectively observed and analyzed. The indices that were used to evaluate the clinical efficacy of VascuTrak balloon catheter included the immediate technical success rate, residual stenosis, successful dilation times, degree of pain assessed using the Visual Analog Scale, complications, and follow-up patency rate.

RESULTS

The stenotic or occlusive lesions of all 51 cases resistant to conventional balloon angioplasty were promptly eliminated or alleviated (residual stenosis rate ≤ 30%), with a 100% immediate technical success rate. VascuTrak balloon catheters were successful in achieving full dilation under working pressure, of which 44 cases required a 1-time dilation (86.3%) and 7 cases required 2 dilations, which differed significantly from the average of 2.4 dilations required by the preceding conventional balloon therapy (P < 0.0001). A statistically significant improvement in the degree of pain experienced by patients who received VascuTrak balloon dilation was observed compared to that of the preceding conventional balloon dilation (P < 0.0001). One case of a brachial artery pseudoaneurysm complication occurred in the perioperative period. The primary patency rate was 88.2% at 6 months and 74.5% at 12 months.

CONCLUSION

The use of VascuTrak balloon catheter to treat autogenous AVF dysfunction resistant to conventional balloon angioplasty appears to be safe and effective, although further, large randomized controlled trials are necessary.

Paclitaxel-Coated Balloons for the Treatment of Symptomatic Central Venous Stenosis in Dialysis Access: Results from a Randomized Controlled Trial

PURPOSE

To compare the clinically-assessed intervention-free period (IFP) of paclitaxel-coated balloon (PCB) vs conventional balloon angioplasty (CBA) for the treatment of symptomatic central venous stenosis (CVS) in dialysis access.

MATERIALS AND METHODS

Within 20 months, 40 dialysis patients (19/40 arteriovenous fistulae [AVFs] and 21/40 arteriovenous grafts [AVGs]) were randomized to undergo angioplasty either with a PCB (PCB group, n = 20; 14/20 male; age: 56.7) or CBA (CBA group, n = 20; 15/20 male; age: 57). There were 15/20 restenotic lesions in PCB group and 12/20 in CBA group. In 25/40 cases, patients had an ipslateral catheter insertion in the past. Primary endpoint was clinically-assessed intervention-free period (IFP) of the treated segment at 6 months, while secondary endpoints included complication rates during follow-up period and identification of factors influencing IFP.

RESULTS

Median IFP was significantly better in PCB group (PCB group: 179 days, vs CBA group: 124.5 days, P = .026). Mean follow-up period was 180 days (range, 5-479). There was no significant difference between AVGs and AVFs (P = .17), treatment of de novo vs restenotic lesions (P = .33), or prior presence of catheter insertion (P = .21). No complications were observed. In restenotic lesions in PCB group, longitudinal comparison between treatments also showed a significant difference in favor of PCB treatment (median IFP in PCB* group 177 vs 91 days in CBA* group; P = .01).

CONCLUSIONS

In this prospective study, PCB had significantly better results compared with CBA for the treatment of symptomatic central venous stenosis in dialysis access. Retrospective longitudinal comparison of treatments in the same patients also showed a significant difference in favor of PCBs.

Drug eluting balloons for resistant arteriovenous dialysis access stenosis

Vascular access maintenance is vital for hemodialysis patients. Conventional balloon angioplasty is the gold standard of treatment in endovascular therapy according to published guidelines, accompanied by bare metal stents as a bail-out method. Several devices have been used so far with a view to improve patency outcomes, but only covered stents have been proposed as a valid alternative and only for venous juxta-anastomotic stenosis of arteriovenous grafts. Paclitaxel-coated balloons (PCBs) have been extensively investigated in the last few years in pilot studies with small numbers of patients in dialysis access. Results from these studies have been promising so far; however, a larger number of subjects is needed to prove outcomes. Aim of this analysis is to discuss current available studies and explore some critical aspects of PCB use in dialysis access treatment.

Paclitaxel-Coated Balloons for the Treatment of Dysfunctional Dialysis Access. Results from a Single-Center, Retrospective Analysis

PURPOSE

To investigate the safety and effectiveness of lutonix paclitaxel-coated balloon (PCB) for the treatment of dysfunctional dialysis access.

MATERIALS AND METHODS

This was a single-center, single-arm, retrospective analysis of 39 patients (23 male, 59 %) undergoing 61 interventions using 69 PCBs in a 20-month period. There was a balance between arteriovenous fistulae (AVF) and grafts (AVG) (20 AVFs, 19AVGs), and the majority of lesions were restenotic (25/39, 64.1 %). Mean balloon diameter used was 6.6 mm and length 73.4 mm. Primary outcome measure was target lesion primary patency (TLPP) at 6 months, while secondary outcome measures included factors affecting TLPP and major complications. As there were lesions treated more than once with PCB, authors also compared patency results after first and second PCB angioplasty.

RESULTS

TLPP was 72.2 % at 6 months with a median patency of 260 days according to the Kaplan-Meier survival analysis. No major complications occurred. TLPP between AVFs and AVGs (311 vs. 237 days, respectively; p = 0.29) and de novo and restenotic lesions was similar (270.5 vs. 267.5 days, respectively; p = 0.50). In 14 cases, in which lesions were treated with two PCB angioplasties, a statistically significant difference in TLPP after the second treatment was noted (first intervention 179.5 days vs. second intervention 273.5 days; p = 0.032).

CONCLUSION

In this retrospective analysis, Lutonix PCB proved to be safe and effective in treating restenosis in dysfunctional dialysis access with results comparable to the literature available. Larger studies are needed to prove abovementioned results.

Cutting balloons, covered stents and paclitaxel-coated balloons for the treatment of dysfunctional dialysis access

Percutaneous transcatheter balloon angioplasty has evolved to the current mainstay treatment for salvage of dysfunctional dialysis access. Nonetheless, it is frequently associated with recurrent vessel restenosis and the need for multiple repeat treatments in order to maintain hemodynamic patency. Cutting-balloons, covered stents or stent-grafts, and paclitaxel-coated balloons have been extensively tested and investigated with the aim to improve immediate anatomical and long-term clinical results. Areas covered: In the present overview, we discuss the background and appraise relevant medical literature on the aforementioned technologies and provide a more in-depth synthesis of the results of different clinical studies for each device category. We will also discuss the limitations in the mode of action of each group of devices and envision what the future holds for the challenging field of dialysis access interventions. Expert commentary: We propose a good practice algorithm for the treatment of thrombosed or dysfunctional dialysis access.

Usefulness of paclitaxel-releasing high-pressure balloon associated with cutting balloon angioplasty for treatment of outflow stenoses of failing hemodialysis arteriovenous shunts

AIM

To evaluate the technical and clinical success, primary patency (PP) and complications of angioplasty performed with paclitaxel-coated balloon (PCBs) associated with cutting balloon and for the treatment of the outflow stenoses of failing hemodialysis arteriovenous shunt.

MATERIAL AND METHODS

From September 2014 to September 2015, 50 patients with 66 stenoses were registered. Vascular accesses were autogenous (n = 20) and prosthetic (n = 30). Stenosis were documented during follow-up with routine echo-color Doppler, clinical evaluation and in the remaining incidentally during fistulography. Angioplasty was performed with cutting balloon and afterward with PCB. The mean follow-up time was 8 months (range 6-15 months). Technical success, clinical success, primary patency and complications were registered.

RESULTS

Technical success was 100 %. Clinical success was 94.7 %. Primary patency rate was 87.7 %; in five patients, a significant re-stenosis (≥50 %) was registered. A residual asymptomatic stenosis (<30 %) was registered in four cases (7 %). No major complications were registered.

CONCLUSIONS

A short-term patency benefit may be obtained including PCB in angioplasty treatment of failing hemodialysis arteriovenous shunts.

Drug-coated balloon angioplasty for dialysis access fistula stenosis

Maintaining vascular access patency represents a tremendous challenge in hemodialysis patients. Although "native" arteriovenous fistula (AVF) is currently recommended as primary vascular access, neointimal hyperplasia stenoses frequently develop, with a risk for AVF thrombosis and vascular access loss. For years, first-line treatment of AVFs stenoses has been percutaneous transluminal angioplasty, generally with high-pressure or cutting uncoated balloons. However, restenosis and reintervention rates remain incredibly high and occur, according to recent studies, in up to 60% and 70% of patients at 6 and 12 months, respectively. Drug-coated balloons delivering paclitaxel at the angioplasty site have proved their superiority in the treatment of coronary and peripheral arterial stenoses. Paclitaxel reduces neointimal hyperplasia and drug-coated balloons, therefore, it represents an attractive option for AVF stenoses. Because data are scarce, the aim of this paper was to review the concepts and current results of drug-coated balloons in AVF stenosis management.

Systematic Review of Drug Eluting Balloon Angioplasty for Arteriovenous Haemodialysis access Stenosis

Background

Native or prosthetic arteriovenous (AV) fistulas are preferred for permanent haemodialysis (HD) access. These are marked with circuit steno-occlusive disease leading to dysfunction or even failure. Late failure rates have been reported as high as 50%. Standard angioplasty balloons are an established percutaneous intervention for HD access stenosis. Reported restenosis rates remain high and practice guidelines recommend a wide 6-month primary patency (PP) of at least 50% for any intervention. Neointimal hyperplasia is one of the main causes for access circuit stenosis. Drug eluting balloon (DeB) angioplasty has been proposed as an alternative intervention to reduce restenosis by local drug delivery and possible inhibition of this process.

Purpose

To systematically assess the reported efficacy and safety of DeB angioplasty in percutaneous management of prosthetic and autologous HD access stenosis.

Methods

Protocol for the review was developed following the PRISMA-P 2015 statement. An electronic database (Medline, EMBASE, Clinical Trials.gov and Cochrane CENTRAL) search was conducted to identify articles reporting on the use of DeB intervention in HD AV access. Backward and forward citation search as well as grey literature search was performed. The MOOSE statement and PRISMA 2009 statement were followed for the reporting of results. Data from the included studies comparing DeBs with non-DeBs were pooled using a random effects metaanalysis model and reported separately on randomised and non-randomised studies.

Results

Six studies reported on 254 interventions in 162 participants (mean 27 ± 10 SD). The pooled mean and median duration of follow-up was 12 and 13 months (range 6-24 months). These comprised two randomised control trials (RCTs) and four cohort studies. Participant's mean age was 64 ± 5 years and 61% were male. Target lesions (TLs) ranged from under 2 mm to 5.9 mm and 51 were reported as de novo stenosis. Device failure described as wasting of the DeB was reported in two studies (55% and 92.8%). At 6 months TL PP was reported between 70% to 97% for DeBs in the RCTs and cohort studies, and 0% to 26% for non-DeBs. TLs treated with DeBs were associated with a higher primary patency at 6 months as compared to non-DeB balloons (RCTs: odds ratio [OR] 0.25, 95% CI 0.08 to 0.77 and I2 = 19%, cohort studies: OR 0.10, 95% CI 0.03 to 0.31 and an I2 = 20%). No procedure-related major or minor complications were reported.

Conclusions

Current literature reports DeBs as being safe and may convey some benefit in terms of improved rate of restenosis when used to treat AV access disease. However, this body of evidence is small and clinically heterogeneous. A large multicentre RCT may help to clarify the role of DeBs in the percutaneous treatment of AV HD access stenosis.

Advanced Stent Graft Treatment of Venous Stenosis Affecting Hemodialysis Vascular Access: Case Illustrations

Surgically placed dialysis access is an important component of dialysis replacement therapy. The vast majority of patients undergoing dialysis will have surgically placed accesses at some point in the course of their disease, and for many patients these accesses may represent their definitive renal replacement option. Most, if not all, arteriovenous fistulae and grafts will require interventions at some point in time. Percutaneous angioplasty is the typical first treatment performed for venous stenoses, with stents and stent grafts being reserved for patients in whom angioplasty and surgical options are exhausted. In some salvage situations, stent graft placement may be the only or best option for patients. This article describes, using case illustrations, placement of stent grafts in such patients; a focus will also be made on the techniques utilized in such salvage situations.

Arteriovenous fistula in dialysis patients: Factors implicated in early and late AVF maturation failure

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.

Paclitaxel Drug-eluting Balloons to Recurrent In-stent Stenoses in Autogenous Dialysis Fistulas: A Retrospective Study

Purpose

To assess the effect of the Medtronic paclitaxel drug-eluting balloon (DEB) on re-intervention to in-stent stenoses in autogenous dialysis arteriovenous fistulas (AVFs).

Background

AVF is the optimum haemodialysis access. The commonest problem is stenosis, preventing maturation, causing inadequate dialysis or precipitating occlusion. Conventional angioplasty has a high recurrence rate. Successful drug elution in the coronary circulation led us to use DEBs in recurrent AVF stenoses since 2010.

Methods

This is a retrospective study, based on prospective audit data, using DEBs on recurrent in-stent stenotic lesions in the AVF circuit of our haemodialysis population. To analyse the effect of DEBs on re-intervention, we created two Kaplan–Meier curves. The first curve compares the last “disease-free-interval” pre-DEB intervention to the first “disease-free interval” post-DEB, giving us “re-intervention-free percentage at 12 months” pre- and post-DEB. The second curve takes into account the multiple pre- and post-DEB interventions to the index lesion, and uses a marginal proportional hazards model to estimate the hazard ratio for “DEBpresent vs. DEBabsent”.

Results

From 1 September 2010 to 1 December 2013, we treated 625 AVF stenoses with endovascular techniques. In 86 of these stenoses, DEBs were used. Of the 86 DEB interventions, 37 were included for this study, 49 were excluded. In the study group, there was a significant difference in “re-intervention-free percentage at 12 months” before and after DEB: 19% vs. 69%. The hazard ratio for “DEBpresent” vs. “DEBabsent” was 0.23 (95% CI 0.14 to 0.36, p<0.001).

Conclusions

This retrospective study suggests that DEBs significantly reduce re-intervention on recurrent in-stent AVF stenoses.