Choosing the right treatment for the right lesion, Part II: a narrative review of drug-coated balloon angioplasty and its evolving role in dialysis access maintenance

Abstract

Background and Objective: Drug-coated balloons (DCBs) seek to inhibit restenosis in treated hemodialysis access lesions by delivering an anti-proliferative agent (paclitaxel) into the vessel wall. While DCBs have proven effective in the coronary and peripheral arterial vasculature, the evidence for their use in arteriovenous (AV) access has been less robust. In part two of this review, a comprehensive overview of DCB mechanisms, implementation, and design is provided, followed by an examination of the evidence basis for their use in AV access stenosis.Methods: An electronic search was performed on PubMed and EMBASE to identify relevant randomized controlled trials (RCTs) comparing DCBs and plain balloon angioplasty from January 1, 2010 to June 30, 2022 published in English. As part of this narrative review, a review of DCB mechanisms of action, implementation, and design is provided, followed by a review of available RCTs and other studies.Key Content and Findings: Numerous DCBs have been developed, each with unique properties, although the degree to which these differences impact clinical outcomes is unclear. Target lesion preparation, achieved by pre-dilation, and balloon inflation time have proven important factors in achieving optimal DCB treatment. Numerous RCTs have been performed, but have suffered from significant heterogeneity, and have often reported contrasting clinical results, making it difficult to draw conclusions on how to implement DCBs in daily practice. On the whole, it is likely there is a population of patients who benefit from DCB use, but it is unclear which patients benefit most and what device, technical, and procedural factors lead to optimal outcomes. Importantly, DCBs use appears safe in the end-stage renal disease (ESRD) population.Conclusions: DCB implementation has been tempered by the lack of clear signal regarding the benefits of DCB use. As further evidence is obtained, it is possible that a precision-based approach to DCBs may shed light onto which patients will truly benefit from DCBs. Until that time, the evidence reviewed herein may serve to guide interventionalists in their decision making, knowing that DCBs appear safe when used in AV access and may provide some benefit in certain patients.

Effect of Umbilical Cord Mesenchymal Stem Cells on Vascular Maturation in Rabbit Arteriovenous Fistula (AVF) Model Assessed Using Doppler Ultrasonography

“…Several mechanisms underlie stenosis, including hypoxia, inflammation, and shear stress that promote venous neointimal hyperplasia. 19 The mean vascular hyperplasia in the group that was given in situ MSCSs (Group P2) showed the smallest value compared to the other groups. In line with these findings, a study by Barcena AJR, et al 20 also find that MSCSs administration has significant potential to increase AVF maturation.…”

Dialysis Access Maintenance: Plain Balloon Angioplasty

“…However, the response of lesions at various anatomical sites such as cephalic arch stenoses versus anastomotic lesions is likely to be different given the different haemodynamic forces. This is discussed at some length in a separate review [55]. The use of PBA in fistulas of different ages as well as primary treatment versus treatment of recurrent lesions may also affect the outcomes.…”