If correctable pathology is detected in patients with early fistula failure, the incidence of correctable lesions is relatively high and an aggressive therapeutic approach can be expected to have a high yield.
Hemodialysis vascular access catheters are essential in the maintenance of hemodialysis vascular access. However, they have a significant infectious, thrombotic, anatomic complication rate that are detailed with proposed problem-solving guidelines.
This study was undertaken to evaluate percutaneous transvenous angioplasty (PTVA) for the treatment of all types of vascular access stenosis in a large population of dialysis patients. Stenoses were identified by venography in patients who met a set of clinical criteria indicating the need for evaluation. The lesions were classified by location and type. Data were collected prospectively and analyzed separately for each lesion type. A total of 536 PTVA procedures was performed in 285 patients. This included 107 cases of long venous stenosis (> 6 cm) and 149 cases of mid-graft stenosis. In the total group, an initial success rate of 94% was obtained (80% or greater dilatation). A decrease in VPm (venous pressure measured on dialysis) of 35.9%, 32.4%, and 22.6% was seen at one week, one month, and three months, respectively. At 90 days, 180 days, and 360 days 90.6%, 61.3%, and 38.2%, respectively, of the treated grafts were continuing to be patent and functional with no need for repeat PTVA treatment. Repeat treatments for recurrent lesions were as successful as the initial treatment. It is concluded that vascular access stenosis can be easily diagnosed and that all categories of stenotic lesion can be effectively treated with PTVA.
A significant number of arteriovenous fistulae (28 to 53%) never mature to support dialysis. Often, renal physicians and surgeons wait for up to 6 months and even longer hoping that the arteriovenous fistula (AVF) will eventually grow to support dialysis before declaring that the AVF has failed. In the interim, if dialysis is needed, then a tunneled catheter is inserted, exposing the patient to the morbidity and mortality associated with the use of this device. In general, a blood flow of 500 ml/min and a diameter of at least 4 mm are needed for an AVF to be adequate to support dialysis therapy. In most successful fistulae, these parameters are met within 4 to 6 wk. Most important, commonly encountered problems (stenosis and accessory veins) that result in early AVF failure can be diagnosed easily with skillful physical examination. Recent studies have indicated that a great majority of fistulae that have failed to mature adequately can be salvaged by percutaneous interventions and become available for dialysis. Early intervention regarding identification and salvage of a nonmaturing AVF is critical for several reasons. First, an AVF is the best available type of access regarding complications, costs, morbidity, and mortality. Second, this approach minimizes catheter use and its associated complications. Finally, access stenosis is a progressive process and eventually culminates in complete occlusion, leading to access thrombosis. In this context, the opportunity to salvage the AVF that fails early may be lost. This report reviews the process of AVF maturation and suggests a strategy for when and how to intervene to identify and salvage AVF with early failure.
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