Choosing the right treatment for the right lesion, part I: a narrative review of the role of plain balloon angioplasty in dialysis access maintenance

Abstract

Background and Objective: The majority of patients with end-stage renal disease (ESRD) requiring hemodialysis (HD) do so via an arteriovenous fistula (AVF) or graft. Both of these accesses are complicated by dysfunction related to neointimal hyperplasia (NIH) and subsequent stenosis. Percutaneous balloon angioplasty using plain balloons is the first line treatment for clinically-significant stenosis, with excellent initial response rates, however, with poor long-term patency and need for frequent reintervention. Recent research has sought to improve patency rates utilizing antiproliferative drug-coated balloons (DCBs), however, their role in treatment has not yet been fully determined. In part one of this two-part review, we aim to provide a comprehensive overview of the mechanisms of arteriovenous (AV) access stenosis, the evidence behind their treatment with high-quality plain balloon angioplasty techniques, and treatment considerations for specific stenotic lesions.Methods: An electronic search was performed on PubMed and EMBASE to identify relevant articles from 1980 to 2022. The highest available level of evidence regarding stenosis pathophysiology, angioplasty techniques, and approaches to treating different types of lesions within fistulas and grafts were included as part of this narrative review.Key Content and Findings: NIH, and subsequent stenoses, develop via a combination of upstream events, causing vascular damage, and downstream events, representing the subsequent biologic response.The large majority of stenotic lesions can be treated utilizing high-pressure balloon angioplasty, with the addition of ultra-high pressure balloon (UHPB) angioplasty for resistant lesions and prolonged angioplasty with progressive balloon upsizing for elastic lesions. Additional treatment considerations must be taken into account when treating specific lesions, including cephalic arch and swing point stenoses in fistulas and graftvein anastomotic stenoses in grafts, amongst others.Conclusions: High-quality plain balloon angioplasty, performed utilizing the available evidence-basis regarding technique and considerations for specific lesion locations, is successful in treating the large majority of AV access stenoses. While initially successful, patency rates remain non-durable. Part two of this review will discuss the evolving role of DCBs, which seek to improve angioplasty outcomes.

A Cost‐Effective Approach to Resistant AV Fistula Stenosis: Successful Treatment Using Coronary OPN NC® Balloon in a Low‐Income Setting

“…In such cases, high pressure (up to 20 atm) or ultra-high pressure (>20 atm) balloon angioplasty is required for successful treatment. High-or ultra-high-pressure PTA provides a technical success rate of 90%-95% compared to regular pressure PTA [9,10]. Angioplasty has a 4% complication risk, with hematoma development being the most prevalent adverse effect, followed by decrease oxygen saturation and adverse drug effect [2].…”

Efficacy of cutting balloon angioplasty versus high-pressure balloon angioplasty for the treatment of arteriovenous fistula stenoses in patients undergoing hemodialysis: Systematic review and meta-analysis

“…A high-pressure balloon, delivering 24 to 36 Pa of dilatation pressure, can mechanically disrupt the dense fibrous tissue in the stenotic segment, thus enhancing the success rate of percutaneous balloon dilatation angioplasty in treating these lesions. Studies have suggested that the patency rate of high-pressure balloon treatment for refractory arteriovenous fistula stenosis is approximately 39% to 43% six months after surgery [ 12 , 13 ]. High-pressure balloons have been widely applied for the treatment of refractory arteriovenous fistula stenosis [ 14 ]; however, whether to use a high-pressure balloon or a cutting balloon for patients with stenosis of the internal arteriovenous fistula remains controversial [ 15 ].…”

Single-Cell Analyses Offer Insights into the Different Remodeling Programs of Arteries and Veins

“…While it is widely recognized that the different etiologies of stenotic lesions in arteries vs. veins play a significant role in the efficacy of treatments [9,10], most comparative pathophysiological studies have been limited to histology [9,11,12]. Compared with veins, arteries have a thicker media and better-defined elastic laminas as an adaptation to high blood pressure and pulsatile flow [13,14].…”