Percutaneous Arteriovenous Fistula Creation with the 4 French WavelinQ™ EndoAVF System

BACKGROUND

Percutaneous devices for creation of native arteriovenous fistulae offer an alternative to traditional open surgical techniques. The 4 Fr WavelinQ EndoAVF System was developed as a lower profile alternative to facilitate access through smaller vessels and minimize access site complications; The current report is the original first experience of this device, assessing outcome in 120 patients followed for 6 months.

METHODS

The use of the 4 Fr WavelinQ system in three studies, EASE (32 patients), EASE-2 (24 patients), and the EU post-market clinical follow-up study (64 patients) was aggregated and analyzed. Patients were followed with duplex ultrasound at discharge and follow-up visits at 1, 3, and 6 months. Primary, assisted primary, and secondary patency rates were evaluated as Kaplan-Meier (KM) estimates and standard errors. Time to maturity and time to successful cannulation were defined as the mean ± SD days from the procedure in patients enrolled on dialysis.

RESULTS

Procedural success was achieved in 116 patients (96.7%). Primary, assisted-primary, and secondary 6-month patency rates were 71.9%±4.5%, 80.7%±4.1%, and 87.8%±3.3%, respectively. Time to maturity averaged 41±17 days. Time to successful cannulation averaged 68±51 days. Device-related serious adverse events were reported in 3/120 patients (2.5%) and procedure-related serious adverse events occurred in 7/120 patients (5.8%). Arterial or venous access complications were not reported in any of the patients. Access circuit reinterventions were performed in 23 patients (19.2%), split between those performed for EndoAVF maturation (13/120, 10.8%) and maintenance (11/120. 9.2%).

CONCLUSIONS

Percutaneous creation of native dialysis fistulae with the 4 Fr WavelinQ EndoAVF System is safe and effective, with favorable durability and a low rate of serious complications and reinterventions through 6-month follow-up. Utilization of the 4F device allows for percutaneous fistula creation between the radial artery and radial vein or the ulnar artery and ulnar vein. These findings suggest that the 4 Fr device is a useful percutaneous alternative to open surgical AVF or endovascular AVF with larger-bore devices.

Endothelial expression of the alpha6beta4 integrin is negatively regulated during angiogenesis

Development and homeostasis of the vascular system requires integrin-facilitated cellular adhesion, migration, proliferation and survival. A specific role for the alpha6beta4 integrin in the vasculature, however, has not been identified. Using immunohistochemistry, we observed alpha6beta4 expression on the dermal microvasculature of human foreskin. Analysis of individual cells isolated from trypsin-disrupted foreskin tissue indicated that alpha6beta4 was expressed by a subset of epithelial and endothelial cells, and not by smooth muscle cells. Expression of alpha6beta4 was also analyzed during new vessel growth using explants of human saphenous vein cultured in fibrinogen gels. The results indicate that alpha6beta4 is not expressed by outgrowing endothelial cells, and is downregulated by the original alpha6beta4-positive endothelial cells of the explant. To determine whether alpha6beta4 is expressed during angiogenesis in vivo, the expression of the beta4 subunit was analyzed during the development of the mouse mystacial (whisker) pad. Immunohistochemical staining of the whisker pad indicates that beta4 is expressed by the adult vasculature. To identify when and where beta4 is turned on in the vasculature, we examined the whisker pads from the developing embryo (E19.5 pc), and from postnatal days zero (P0), three (P3) and seven (P7) pups. The expression of alpha6beta4 was found to be turned on spatially and temporally from caudal to rostral regions and from the deep to superficial vasculature, correlating with the maturation of the whisker pad and its corresponding vasculature. Together, these findings suggest a potential role for alpha6beta4 as a negative component of the angiogenic switch, whereas expression of alpha6beta4 on the adult vasculature may indicate regions requiring additional adhesive mechanisms.