Single-Sheath Inverse Technique via Vertical Puncture in Hemodialysis Arteriovenous Fistula Angioplasty

Abstract

Background: Transvenous percutaneous transluminal angioplasty for dialysis access stenosis is sometimes for both the upstream and downstream side of the approach site. A single sheath inversion has been used in some cases, but there are few reports in the literature. The purpose of this study was to retrospectively evaluate the feasibility of the sheath inverse technique using the vertical puncture approach in PTA for stenosis of arteriovenous fistulas for hemodialysis. Materials and Methods: Twenty patients (26 cases; 13 males; median age, 74 [range: 50–89] years) who underwent percutaneous transluminal angioplasty using the sheath inverse technique for native arteriovenous fistula stenosis between April 2019 and June 2023 were included. A 4-cm sheath (4Fr, 4 cases; 5Fr, 19 cases; 6Fr, 3 cases) was inserted by vertical puncture through a cutaneous vein in the forearm (20 cases) or upper arm (6 cases). After treating one side of the lesion, the sheath was reversed to treat the lesion on the opposite side. The vessel diameter at the sheath insertion site, the success rate of sheath inversion, the number of percutaneous transluminal angioplasty balloon catheters used, the percutaneous transluminal angioplasty success rate, and adverse events were evaluated. Results: The median diameter at the sheath indwelling site was 5.2 (range: 3.6–9.5) mm, and sheath inversion was successful in all cases. The number of balloon catheters used was oneand two in 17 (65%) and eight cases (31%), respectively, and three in one case wherein a drug-coated balloon was used. Major complications were not observed. However, in one case wherein a sheath had to be placed at the arterial needle puncture site, the skin was hard, leading to difficulty in inversion, and transient venous spasm occurred post-inversion. Conclusion: The single-sheath inverse technique for arteriovenous fistulas was feasible without sheath withdrawal.