ENDOVASCULAR TREATMENT OF MALFUNCTIONING HAEMODIALYSIS GRAFTS/FISTULAS. Dr R Uberoi Interventional Radiologist John Radcliffe hospital Oxford.

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1 ENDOVASCULAR TREATMENT OF MALFUNCTIONING HAEMODIALYSIS GRAFTS/FISTULAS Dr R Uberoi Interventional Radiologist John Radcliffe hospital Oxford.

2 Stenosis Stenosis Native fistula/grafts. Radio-cephalic 55-75% of stenosis in proximity to the anastamosis 25% in the outflow tract. Brachio-cephalic and brachio-basilic stenosis most commonly at the cephalic - subclavian junction Basilic -junction with the axillary vein Grafts in the body. Central stenosis-common 30-50% Percutaneous transluminal angioplasty standard of care treatment for correction of stenosis in AVF and AV graft. Turmel-Rodrigues L, Pengloan J, Baudin S, et al. Treatment of stenosis and thrombosis in haemodialysis fistulas and grafts by interventional radiology. Nephrol Dial Transplant 2000; 15: Rajan DK, Bunston S, Misra S, Pinto R, Lok CE. Dysfunctional autogenous hemodialysis fistulas: outcomes after angioplasty--are there clinical predictors of patency? Radiology 2004; 232:

3 PTA Technical success 88-94% native veins 98% grafts. Primary patency rates 55-77% at 6 months 26-68% at 12 months 60% at 18 months 40% at 24 months. Secondary patency rates 72-90% at 6 months 72-85% at 12 months 68% at 18 months Central stenosis-10% patency at 12 months Complications 4-5% (haematoma and rupture) Catastrophic vessel rupture in <1% Turmel-Rodrigues L, Pengloan J, Baudin S, Testou D, Abaza M, Dahdah G, Mouton A, Blanchard D. Treatment of stenosis and thrombosis in haemodialysis fistulas and grafts by interventional radiology. Nephrol Dial Transplant. 2000;15: Manninen HI, Kaukanen ET, Ikäheimo R, et al. Brachial arterial access: endovascular treatment of failing Brescia-Cimino hemodialysis fistulas--initial success and long-term results. Radiology 2001; 218: Clark TW, Hirsch DA, Jindal KJ, Veugelers PJ, LeBlanc J. Outcome and prognostic factors of restenosis after percutaneous treatment of autologous hemodialysis fistulas. J Vasc Interv Radiol 2002; 13:51-59 Lay JP, Ashleigh RJ, Tranconi L, Ackrill P, Al-Khaffaf H. Result of angioplasty of brescia-cimino haemodialysis fistulae: medium-term follow-up. Clin Radiol 1998; 53:

4 Cutting balloons Create a dissection plane then a standard balloon to desired size. Used most commonly for failed venoplasty particularly anastomotic sites. Some advocate primary use to reduce the barotrauma during venoplasty. Primary patency rates at 88%, 73% and 34% at 6, 12, and 24 months A comparative study showed primary patency 100% v 97.1%, 88.6% v 62.9%, 71.4%v42.9% at,3,6 and 12 months. Meta-analysis 1034 patients Six-month target lesion patency significantly higher in PCB angioplasty (67.2% vs. 55.6% RD 0.12; 95%CI ; P < 0.05) Increase risk of rupture. Cutting balloons should not be used immediately after standard balloon venoplasty Bittle JA. Venous rupture during percutaneous treatment of haemodialysis fisutlas and grafts. Catherter Cardiovasc Interv 2009 Bhat R, McBride K, Chakraverty S, Vikram R, Severn A. Primary cutting balloon angioplasty for treatment of venous stenosis in native hemodialysis fistulas: long-term results from three centers. Cardiovasc Intervent Radiol 2007;30(6): Peregrin JH, Rocek M. Results of a peripheral cutting balloon prospective multicentre European vascular access. Cardiovasc Intervent Radiol 2007;30: Wu CC,Senn CC Cutting balloon angioplasty for resistant venous stenosis of dialysis access: Immediate and patency results. Cath Cardiov Interv 2008:71: Wu CC, Lin MC, Pu SY, et al., Comparison of cutting balloon versus high-pressure balloon angioplasty for resistant venous stenoses of native hemodialysis fistulas, J Vasc Interv Radiol, 2008;19: Agarwal SK 1, Nadkarni GN 2, Yacoub R et all Comparison of Cutting Balloon Angioplasty and Percutaneous Balloon Angioplasty of Arteriovenous Fistula Stenosis: A Meta-Analysis and Systematic Review of Randomized Clinical Trials. J Interv Cardiol Jun;28(3):

5 Stents-Early studies no benefit Stents function as an endoskeleton and provide supportive expansion to diseased vessels. In 65 patients with self-expanding stainless steel stents for failing or occluded dialysis accesses thrombosis in 10% of patients within 1 week. In a series of 52 patients,the primary patency at 6 months was only 46% after placement of stents. Prospective randomized trial of 58 patients > 50%, Gianturco Rosch Z metallic stent conferred no advantage in duration of patency at 30, 60, 90, 180 or 360 d Quinn et al. showed, in their randomized study, that primary and secondary patency for PTA versus stents was comparable 87 prospective patients over a 3-yr period, the primary patency rates for PTA at 60, 180, and 360 d were 55%, 31%, and 10%, respectively, and for stents were 36%, 27%, and 11%, respectively. Vorwerk D, Guenther RW, Mann H, et al. Venous stenosis and occlusion in hemodialysis shunts: follow-up results of stent placement in 65 patients. Radiology 1995;195: Kim CY et al, Outcome of prosthetic haemodialysis grafts after deployment of bare versus covered stents at the venous anastomosis. Cardiovasc Interv Radiol (2012): 35: Beathard GA: Gianturco self-expanding stent in the treatment of stenosis in dialysis access grafts. Kidney Int43 : ,1993 Sheley RC: Percutaneous transluminal angioplasty versus endovascular stent placement in the treatment of venous stenoses in patients undergoing hemodialysis: intermediate results. J Vasc Interv Radiol6 : ,1995

6 Stents Vogel and Parise demonstrated increase in mean primary patency(64pts AVG) from 2.5 months with angioplasty to 10.6 months after nitinol SMART stent Prospective, nonrandomized trial in 60 patients upper extremity AVGs Significant decrease in restenosis in the stent group compared with angioplasty (7% v 16%; P = 0.001) Improvement in mean primary graft patency (5.6 v 8.2 mo; P = 0.05) Vogel PM, Parise C: SMART stent for salvage of hemodialysis access grafts. J Vasc Interv Radiol15 : ,2004 Vogel PM, Parise C: Comparison of SMART stent placement for arteriovenous graft salvage versus successful graft PTA. J Vasc Interv Radiol16 : ,2005

7 Stents Graft patency after thrombectomy and placement of a nitinol stent(14 pts) compared with PTA(34) alone. The primary graft patency significantly longer for the stent group Median survival, 85 versus 27 d( P = 0.02) Secondary patency (median survival, 1215 versus 46 d; P = 0.049). 61 pts with AVG -Primary patency for PTA 32% at 3 months, 24% at 6 months, and 14% at 12 months Stenting 85%, 63% and 49% (P <.001). Cumulative median patency was 60 days for PTA and 260 days for stenting. 211 patients primary assisted AVG (99) patency significantly longer for the stent group compared with angioplasty, Median survival of 138 versus 61 d, respectively (ahr = 0.17; 95% confidence interval, 0.07 to 0.39; P < 0.001). The primary AVG patency for stent versus angioplasty was 91% versus 80% at 30 d, 69% versus 24% at 90 d, and 25% versus 3% at 180 d, respectively. The primary assisted AVF(112) patency did not differ significantly between the stent and angioplasty groups. Maya ID, Allon M: Outcomes of thrombosed arteriovenous grafts: comparison of stents vs angioplasty. Kidney Int69 : ,2006 Chan MR, Bedi S, Sanchez RJ, Young HN, Becker YT, Kellerman PS, Yevzlin AS. Stent placement versus angioplasty improves patency of arteriovenous grafts and blood flow of arteriovenous fistulae. Clin J Am Soc Nephrol May;3(3): doi: /CJN Epub 2008 Feb 6 Kakisis JD, Avgerinos E, Giannakopoulos T, Moulakakis K, Papapetrou A, Liapis CD. Balloon angioplasty vs nitinol stent placement in the treatment of venous anastomotic stenoses of hemodialysis grafts after surgical thrombectomy. Vasc Surg Feb;55(2):472-8

8 Stentgrafting 17 pts with Fluency plus Improvement in graft survival (88.2% at 6 months and 86.2% at 12 months) over conventional surgical or angioplasty techniques. Fifty Viabahn stents deployed in 37 consecutive patients - Overall Kaplan-Meyer PPs were 60% at 12 months and 42% at 24 months. Estimated PP rates at 12 and 24 months for long segment recanalization procedure were 53% and 31%, respectively. Female sex, access age and thrombosis were associated with reduced primary patency. Stentgraft- Fluency plus in 104 patients,technical success 98% -Primary 47% (62% AVF and 35% grafts), secondary 79% at 6 months. Smaller grafts less well 63%v38% 9-10mm v 6-8mm Not cross the elbow 47% v 25% 58 patients 32 BM v 29 Stentgrafts Primary 50%v59%, 41%v52% and 22%v29% at 3,6 and 12 months. Cephalic arch -Six month primary patency for bare stents and stent grafts were 39%, and 82%, respectively; one year primary patency was 0%, and 32%, respectively, with a significant statistical difference of p = at one year Shemesh D, Goldin I, Zaghal I, Berlowitz D, Raveh D, Olsha O. Angioplasty with stent graft versus bare stent for recurrent cephalic arch stenosis in autogenous arteriovenous access for hemodialysis: a prospective randomized clinical trial. Journal of vascular surgery. 2008; 48(6): e Bent CL etal JVIR 2010:21: Dolmatch B L et al JVIR 2012:23: Kim CY et al. CVIR 2012:35:

9 Stentgraft V PTA 190 patient randomised stent graft group significantly better primary patency at 6 months (51% for stent graft group and 23% for PTA group, p < 0.001) and better access circuit patency (38% for stent graft group and 20% for PTA group, p = 0.008) No significant difference between the two groups in access circuit assisted patency and access circuit cumulative patency rates REVISE -295 patients randomized, and 293 patients comprising the Intent-To-Treat (ITT) analysis group. 145 patients to the stent group and 148 subjects to the PTA group, although 24 patients later excluded from the effectiveness analysis. 24-month 65 patients in each arm. Primary patency at 6 months, 12 months, and 24 months was 52.9%, 30.2% and 15.7%, respectively, for the stent group and 35.5%, 18.2%, and 9.9%, respectively, for the PTA group (p = 0.008). Access circuit primary patency was 21.4% and 9.6% for stent group and 15.2% and 6.8% for the PTA group, at 12 and 24 months respectively (p = 0.035). No statistically significant difference between the groups in assisted primary patency, access secondary patency, or treatment site secondary patency. Haskal ZJ, Trerotola S, Dolmatch B, et al. Stent graft versus balloon angioplasty for failing dialysis-access grafts. The New England journal of medicine. 2010; 362(6): Naoum JJ, Irwin C, Hunter GC. The use of covered nitinol stents to salvage dialysis grafts after multiple failures. Vascular and endovascular surgery. 2006; 40(4): Webb KM, Cull DL, Carsten CG 3rd, Johnson BL, Taylor SM. Outcome of the use of stent grafts to salvage failed arteriovenous accesses. Annals of vascular surgery. 2010; 24(1): [

10 Endovascular Intervention Stentgraft primary patency in 17 patients with AV fistulae of 94.1, 88.2, and 88.2% after 3, 6, and 12 months of follow-up, respectively. Viabil device (GoreMedical, Flagstaff, AZ) much lower porosity than Viabahn or Flair; primary patency rate of 85% at both 2 and 6months 20- patient pilot trial. RESCUE- 275 pts Access site patency 6 months was significantly higher in the stent-graft group (18.6%) versus the PTA group (4.5%; P <.001), 12 months (stent graft, 6.2%; PTA, 1.5%) Increasing evidence to use BM stents but best for covered stents in grafts. Avoid: At venous junctions, dialysis puncture sites or small veins <5mm and in the presence of sepsis. Stent migration/fracture/infection Drug eluting balloons showing great promise for the future. Bent CL, Rajan DK, Tan K, et al. Effectiveness of stent-graft placement for salvage of dysfunctional arteriovenous hemodialysis fistulas. J Vasc Interv Radiol 2010;21(4): Chan MG, Miller FJ, Valji K, Bansal A, Kuo MD. Evaluating patency rates of an ultralow-porosity expanded polytetrafluoroethylene covered stent in the treatment of venous stenosis in arteriovenous dialysis circuits. J Vasc Interv Radiol 2014;25(2): Vesely TM Semin Dial 2005:18: Kim CY et al. CVIR 2012:35: Chan MR, Bedi S, Sanchez RJ, Young HN, Becker YT, Kellerman PS, Yevzlin AS. Stent placement versus angioplasty improves patency of arteriovenous grafts and blood flow of arteriovenous fistulae. Clin J Am Soc Nephrol May;3(3): doi: /CJN Epub 2008 Feb 6 Falk A,Maya ID,Yevzlin AS. RESCUE Investigators. A prospective, randomized study of an expanded polytetrafluoroethylene stent graft versus balloon angioplasty for in-stent restenosis in arteriovenous grafts and fistulae: two-year results of the RESCUE Study. J Vasc Interv Radiol 2016;27:1465e76.

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