Percutaneous transluminal angioplasty in the treatment of stenosis of hemodialysis arteriovenous fistulae: our experience Poster No.: C-3355 Congress: ECR 2010 Type: Scientific Exhibit Topic: Interventional Radiology Authors: A. Bazzocchi 1, C. Acciarri 1, E. Mancini 1, A. Casadei 1, R. Canini 1, Keywords: DOI: C. Rossi 2, A. Santoro 1, F. Losinno 1 ; 1 Bologna/IT, 2 Parma/IT hemodialysis, hemodialysis arteriovenous fistulae, transluminal percutaneous angioplasty 10.1594/ecr2010/C-3355 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 9
Purpose The management algorithm of the failing hemodialysis vascular access is still a matter of debate [1, 2]. Stenosis is a frequent cause of dysfunction of hemodialysis arteriovenous fistulae (AVF), but can often be treated by appropriate intervention. Endovascular repair is a widely used salvage strategy before surgical reintervention; the goal is to enable the fistula to survive and to work as long as possible, as better as possible (figure 1 on page 2). Percutaneous transluminal angioplastyon page (PTA on page ) of dysfunctional AVF has become the standard of care for stenosis treatment. Several studies have shown the safety and efficacy of this technique [3-5]. Primary and secondary patency rates are not inferior to surgical intervention and advantages are well known [6, 7]. The aim of this work was to review our single-center experience and to evaluate efficacy and complications of PTA in the treatment of stenosis of AVF. Images for this section: Page 2 of 9
Fig. 1: Multiple venous stenosis before and after PTA. Vascular access after PTA was free from dysfuction for 59 days Page 3 of 9
Methods and Materials We retrospectively analyzed 531 patients undergone hemodialysis between 2004 and 2008 and followed by the Nephrology and Hemodialysis Unit of our hospital. The analysis considered: type of fistula, use of cutting balloon on page 4 (CB on page 4, figure 1 on page 4), incidence of non-stenotic procedure-related complications and number, site and time of stenosis after PTA. Average follow-up time was 731±597 days. Primary patency was considered to begin on the day of the first procedure and to end on the day of access failure, reintervention or end of follow-up. Secondary patency included all further percutaneous procedures and ended on the day of the subsequent access failure, surgical intervention or end of follow-up. Death or renal transplant were considered end of follow-up. Images for this section: Fig. 1: Distal AVF: stenosis and PTA with cutting balloon Page 4 of 9
Results Sixty-eight of 531 patients (12.8% - 49 males and 19 females, age 69±12 years old) incurred stenosis candidate for endovascular treatment and were treated with 115 PTA (figure 1 on page 5); PTA were performed with high pressure balloon catheter; CB was used when simple balloon could not achieve satisfactory results and stent placement was always avoided, when possible. Seventeen of 68 patients (25%) showed recurrence of stenosis. Average follow-up time for these patients was 907±523 days. Fifteen patients had single AVF during the hemodialysis treatment follow-up (8 proximal, 7 distal AVF) and 2 patients needed to get a second AVF (one patient with 2 proximal AVF and the other patient with prosthetic and a following distal AVF). Recurrences of stenosis lesions (single stenosis in 11 patients, multiple stenosis in 6 patients) were submitted to 49 PTA sessions (64 PTA - 7 using CB on page ). Primary treated stenosis were distributed as follows: 2 arterial stenosis, 24 juxta-anastomosis vein stenosis on page, 8 draining vein stenosis, 3 central vein stenosison page 6 (figure 2 on page 6). Restenosis rate per region was: 17/24 (70.8%) juxta-anastomosis vein stenosis, 5/8 (60.3%) draining veins stenosis, 2/3 (66.7%) central vein stenosis. Time before restenosis in proximal AVF and distal AVF was 154±116 days and 245±243 days respectively. Prosthetic AVF (figure 3 on page 6) incurred complete thrombosis after 37 days. Time free from disease on a lesion-based analysis was 192±164 days for primary patency, 207±257 for secondary patency (211±182 days and 135±86 days for juxta-anastomosis veins, 193±116 days and 151±169 days for draining veins, 120 days and 180 days for central veins, respectively). On a patient-based analysis stenosis generally incurred after 211±200 days: primary stenosis after 205±160, restenosis (or new stenosis) after 205±246 (figure 4 on page 7). Only two of 7 stenosis tretated with CB had restenosis (respectively after 48 and 372 days - the first one incurred complete trombosis after 955 days, the second one is still free from disease, both after a second CB procedure). The only non-stenotic complication observed and correlated with the treatment was a venous cleft with hematoma. Images for this section: Page 5 of 9
Fig. 1: Excellent outcome of PTA for a long juxta-anastomotic stenosis Fig. 2: Central vein stenosis and PTA Page 6 of 9
Fig. 3: Prosthetic fistula stenosis treated with PTA Page 7 of 9
Fig. 4: Fistulography showed "classical" vein stenosis in a distal AVF. A second PTA session needed after 185 days for recurrence and new stenosis sites Page 8 of 9
Conclusion AVF dysfunction in haemodialysis patients is mainly due to stenosis and this responds well to angioplasty. PTA is an effective treatment to extend the life-time of the vascular access. Time of restenosis after PTA is very variable and the outcome strictly depends on the collaboration between nephrology and radiology teams. References 1. Allon M (2007) Current management of vascular access. Clin J Am Soc Nephrol 2:786-800 2. Campos R, Riella MC (2008) Challenge for the interventional nephrologist: monitoring the arteriovenous fistula. Contrib Nephrol 161:12-22 3. Campos RP, Do Nascimento MM, Chula DC et al (2006) Stenosis in hemodialysis arteriovenous fistola: evaluation and treatment. Hemodial Int 10:152-156 4. Falk A (2008) Maintenance and salvage of arteriovenous fistulas. J Vasc Interv Radiol 17:807-813 5. Cohen A, Korzets A, Neyman H et al (2009) Endovascular interventions of juxta-anastomotic stenoses and thromboses of hemodialysis arteriovenous fistulas. J Vasc Interv Radiol 20:66-70 6. Karakayali F, Basaran O, Ekici Y et al (2006) Effect of secondary interventions on patency of vascular access sites for hemodialysis. Eur J Vasc Endovasc Surg 32:701-709 7. Bakken AM, Galaria II, Agerstrand C et al (2007) Percutaneous therapy to maintain dialysis access successfully prolongs functional duration after primary failure. Ann Vasc Surg 21:474-480 Personal Information Page 9 of 9