Outcomes of Cephalic Arch Stenosis With and Without Stent Placement after Percutaneous Balloon Angioplasty in Hemodialysis Patients

Abstract

Cephalic arch stenosis is a common complication in maintenance hemodialysis (MHD) patients with brachial artery-cephalic vein fistulas and frequently leads to loss of the functioning brachial artery-cephalic vein fistula. There is paucity of conclusive data to guide appropriate management. We examined the risk of recurrence of cephalic arch stenosis after angioplasty compared to angioplasty after stent placement determined by angiography of the involved upper extremity over time in a contemporary cohort of MHD patients treated in two interventional nephrology practices from March 2008 through May 2011. We retrospectively identified 45 MHD patients with evidence of cephalic arch stenosis (age 60 ± 30 years, 45% men) on elective angiograms. The median number of days until another angioplasty was required decreased, starting with a median of 91.5 days after the first, 70.5 days after the second, 85 days after the third, and 56 days after the fourth. Angioplasty is associated with a faster rate of recurrence of cephalic arch stenosis. The placement of intravascular stent seems to prolong the patency compared to angioplasty alone. Clinical trials with a larger sample size will better elucidate the value and timing of angioplasty versus stent placement in cephalic arch stenosis.

A Randomized Prospective Study Comparing Outcomes of Angioplasty versus VIABAHN Stent-Graft Placement for Cephalic Arch Stenosis in Dysfunctional Hemodialysis Accesses

“…In the present prospective study, we observed 0% primary treatment area patency and 0% primary circuit access patency with PTA at 6 months. Although other studies (2,6) observed a 42% rate and a median 91-day access circuit patency period after PTA for CASs, these studies were retrospective (2,6). Even compared with these retrospective outcomes, we observed a 100% 6-month primary access circuit patency with stent-graft placement.…”

“…In another retrospective study of 45 CASs (6), median PTA patency interval was 91.5 days, with a suggestion of improved bare metal stent patency, with a median patency interval of 152 days. Although patency appeared improved with bare metal stents for CASs in this study (6), no description of intervention, follow-up methodology, points of censure, or definitions and estimation of patency were provided, making any comparison problematic. However, as observed by Shemesh et al (3), patency with stent grafts exceeds that observed with bare metal stents.…”

“…One randomized study (3) examined outcomes between bare metal stents and stent grafts and found superior outcomes with stent grafts. Limited available data suggest that bare metal stents themselves are not associated with improved outcomes versus angioplasty (3,6). Stent grafts appear to be a viable solution to overcome the limitations of metal stents, and provide an effective treatment for recalcitrant and/or recurring stenoses.…”

“…There are limited endovascular studies examining outcomes with this specific lesion; among those of which we are aware, all but one are retrospective studies (2)(3)(4)(5)(6). One randomized study (3) examined outcomes between bare metal stents and stent grafts and found superior outcomes with stent grafts.…”

Elastic Recoil after Balloon Angioplasty in Hemodialysis Accesses: Does It Actually Occur and Is It Clinically Relevant?

“…Elastic recoil was more common for stenoses within the cephalic arch compared with all other vein segments within the access circuit. This area was associated with lower technical success and patency after PTA compared with outcomes of PTA within other areas of the access circuit (12)(13)(14). Although the perpendicular portion of the vein is subject to shear forces, and external compression by the deltopectoral fascia was suggested for poorer outcomes, it is unclear if these factors also predispose to elastic recoil.…”