with TEVAR was impressive. With longer follow-up, this may translate into improved survival with fewer long-term complications. Stent Graft versus Balloon Angioplasty for Failing Dialysis-Access GraftsHaskal ZJ, Trerotola S, Dolmatch B, et al. N Engl J Med 2010;362:494-503. Conclusion: Revision of a venous anastomotic stenosis of a prosthetic dialysis access graft with a stent graft provides longer-term patency and freedom from repeat intervention than revision with standard balloon angioplasty.Summary: Secondary patency of hemodialysis grafts is at best 50% at 3 years. Many interventions are typically required to maintain dialysis-access graft patency. The authors sought to test the hypothesis that revision of venous anastomotic stenosis with stent grafts constructed with the same material as the dialysis-access graft itself would improve long-term patency compared with that provided by revision with balloon angioplasty alone. Theoretically, stent graft revision would prevent elastic recoil associated with balloon angioplasty alone and prevent intimal hyperplasia in-growth at the venous anastomosis, resulting in improved patency of the revised grafts.This was a prospective multicenter trial. There were 190 patients undergoing hemodialysis with dialysis-access grafts and a venous anastomosis stenosis that were randomly assigned to receive balloon angioplasty alone or balloon angioplasty plus placement of a stent graft at the site of the venous anastomotic lesion. Patency of the treatment area and patency of the entire vascular access graft were the primary end points.At 6 months, patency of the treatment area was greater in the stent graft group than in the balloon angioplasty group (51% vs 23%, P Ͻ .001). Six-month patency of the dialysis access circuit was improved in the stent graft group vs the balloon angioplasty group (38% vs. 20%, P ϭ .008). Freedom from subsequent intervention at 6 months was also greater in the stent graft group than in the balloon angioplasty group (32% vs 16%, P ϭ .03). Restenosis was greater in the balloon angioplasty group than in the stent graft group (78% vs 28%, P Ͻ .001). Other adverse events at 6 months were equivalent in the two treatment groups.Comment: There is still a need for dialysis-access grafts. Results of this study suggest stent grafts provide better patency in treating venous anastomotic strictures of dialysis-access grafts than that provided by balloon angioplasty alone. Although the results are statistically significant, there are details to be considered before declaring the results clinically significant. Grafts in this study were treated before actual thrombosis. Many access grafts do not come to revision until they have thrombosed, and it is controversial whether surveillance and treatment of patent, but not thrombosed dialysis grafts, actually results in overall prolongation of usable access. In addition, 6 months after revision with a stent graft, there is primary patency in only half the patients. Stent grafts are more expensive than balloon angioplasty a...

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Purpose: Larger feeding artery diameter has been associated with PAVM persistence after embolotherapy. This study assessed the rate of persistence in coil-embolized PAVM with feeding artery diameters 3 mm or smaller, which are being increasingly treated in the hereditary hemorrhagic telangiectasia (HHT) population. Materials: 58 patients (21M:37F, mean age 43y, range 13-71y), with 141 simple type PAVM treated from 2004 to 2014 at a HHT Center of Excellence were analyzed. Inclusion criteria included: one or more PAVM with feeding artery diameter ≤ 3 mm, treatment with coil embolization, and presence of a follow-up chest CTA at~6 months post embolotherapy. Using arteriographic images, feeding artery diameter, total coil length, and distance from coil nest to PAVM sac were measured, and a visual coil packing density was estimated. Persistence was assessed for each lesion, where persistence was dichotomized into four tiers as previously described . Each variable was statistically tested for association with the rate of persistence. Results: On follow-up CTA, 97/141 (69%) PAVM showed no visible sac, 5/141 (4%) had a visible sac that was 70% or less of original size, and 9/141 (6%) showed some residual flow in the draining vein. The 30/141 (21%) PAVM with unchanged or minimally reduced sac sizes were classified as persistent lesions. Unlike prior studies, feeding artery diameter, coil size, quantity of coils, type of coils (complex shaped or helical), coil nest length, compaction, and visible packing density did not affect persistence. Coil nest-to-sac distance was directly correlated with persistence (p o 0.003). This result holds true even in nest-to-sac distances less than 1 cm. Conclusions: Small PAVM have a high persistence rate after coil embolotherapy. Most previously described risk factors for PAVM persistence do not seem to apply to these lesions, with the exception of coil nest-to-sac distance.