Percutaneous management of perianastomotic stenosis in arteriovenous fistulae: Results of a prospective study

Abstract

Surgical creation of new anastomosis has been proposed as the preferred treatment for perianastomotic stenoses of fistulae. However, disadvantages of surgical approach have included (1) frequent conversion of fistula to a graft by using synthetic graft material to create a new anastomosis, (2) shortening the length of the cannulation segment by proximal autologous arteriovenous neoanastomosis, and (3) abandoning the fistula altogether in favor of a synthetic graft. We report the results of a prospective study using percutaneous balloon angioplasty (PTA) to treat fistulae with perianastomotic lesions. Seventy-three consecutive patients undergoing 112 PTA procedures for the treatment of perianastomotic lesions were studied. Primary and secondary patency rates were calculated. Procedure success, procedure-related complications, and conversion of fistulae to grafts were recorded. The initial success rate was 97%. The degree of stenosis before and after PTA was 81 +/- 9 and 11+/-11%, respectively. Primary patency rates at 6, 12, and 18 months were 75, 51, and 41%, respectively. Secondary patency rates at 6, 12, and 18 months were 94, 90, and 90%, respectively. Grade I hematoma occurred in three and vein rupture in two cases. No grafts were inserted. These outcomes are superior to those that have been reported for surgery. The outpatient PTA is safe and effective for the management of perianastomotic stenosis. Because of its advantage of fistula preservation, the percutaneous approach should be considered as the preferred first-line therapy for the management of perianastomotic fistula lesions.

Efficacy of Percutaneous Transluminal Angioplasty on Dysfunctional Fistulae Because of Inflow Stenosis

“…The estimated secondary patency is rather good and comparable to others (8,19). It is not possible to draw any definitive conclusions as statistical analysis was only performed in seven cases.…”

“…Venous problems have been regarded as the principal culprits for access dysfunction for a long time, with much less importance given to inflow problems which had an incidence of 0% to 4% (12). Although, in the last few years, inflow stenoses have been shown to be present in approximately 25% to 50% of the dysfunctional access (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26). Both radiocephalic and brachiocephalic fistulas commonly fail because of lesions located within the perianastomotic region; however, more proximal stenoses can also occur in both cases, especially in the case of brachiocephalic fistulas (cephalic arch stenosis) (27).…”

“…Other surveillance techniques are associated with earlier detection of stenotic lesions, particularly when dysfunction comes from inflow lesions; however physical examination remains an invaluable monitoring method (25). sites along the drainage vein (9,19). In fact, percutaneous angioplasty has demonstrated disappointing data on the management of cephalic arch stenosis, probably because of multiple factors including the resistant nature of the stenosis, the development of early restenosis, as well as poor patency and high vein rupture rates (27).…”

“…PTA is considered the preferred method of treatment for dysfunctional AVF since it appears to be as efficient as the surgical approach in terms of access survival and cost, even if primary patency for pre-emptive surgical repair is better (89%±6, at 12 months) (16)(17)(18)(19) . Surgery resolves AVF dysfunction by creating a new, more proximal anastomosis with subsequent venous capital loss, or by using graft interposition.…”

Novel Paradigms for Dialysis Vascular Access

“…Our current clinical paradigm views nonmaturing AVF as a plumbing problem, with efforts directed at augmenting access flow by surgical or percutaneous interventions (2)(3)(4). Unfortunately, the very same interventions utilized to salvage immature fistulas also result in vascular injury, which in turn promotes recurrent intimal hyperplasia, rapid re-stenosis, shortened cumulative AVF survival, and the need for frequent interventions to maintain longterm AVF patency for dialysis (5,6).…”