Stent Graft for Nephrologists

Abstract

The role of the stent graft is emerging in the management of arteriovenous dialysis access. Physicians are incorporating this device in the management of three distinct problems-vein-graft anastomotic stenosis, pseudoaneurysm formation, and cephalic arch stenosis-with varying degrees of success. Indeed, a recent randomized, controlled trial to evaluate the role of angioplasty plus stent graft versus angioplasty alone for the management of stenosis at the vein-graft anastomosis led to the approval of the stent graft by the Food and Drug Administration; however, several elements of the management of stenosis at the vein-graft anastomosis/cephalic arch as well as the repair of pseudoaneurysms by stent graft remain controversial. The situation is further complicated and warrants a cost-to-benefit ratio analysis when the added cost of the device is appended to the procedure. In contrast to the controversies, angioplasty-induced complete vascular rupture is one situation in which a stent graft is indicated beyond any doubt. With recent conditional Food and Drug Administration approval, it is anticipated that the use of stent grafts might increase in our patients. In this context, it is critically important that nephrologists be familiar with the current controversies and consensus that surround the use of stent grafts for dialysis access. Just as therapeutic interventions are analyzed in other disciplines within nephrology, these experts must appraise the use of this device for dialysis access. This report presents an up-to-date synopsis on the use of the stent graft that would assist renal physicians in requesting or rejecting the device for the optimal management of their patient's vascular access dysfunction.

A Patient with Recurrent Arteriovenous Graft Thrombosis

“…Moreover, the frequency of AVG thrombosis did not differ between the two groups. Given the high expense of stent grafts (approximately $2000 each) and their unproven benefit in terms of preventing AVG thrombosis, their routine deployment to treat AVG stenosis cannot be justified at this time (26). Two larger ongoing RCTs, RENOVA (flair endovascular stent graft post-approval trial) and REVISE (Gore Viabahn endoprosthesis versus percutaneous transluminal angioplasty to revise arteriovenous grafts at the venous anastomosis in hemodialysis patients) are evaluating two different brands of stent grafts to assess whether they improve AVG patency after angioplasty of a venous anastomotic stenosis.…”

Stent use for hemodialysis access: What a general nephrologist needs to know

“…25 The other common cause for stent fracture is when placed across joints especially across the elbow or the shoulder joint. 27,28 When the stents thrombose in peripheral lesions they can present with clotted dialysis access while if they thrombosis when placed in central lesions based on the collateral supply could present with acute central vein occlusion syndrome. 17,26 Acute stent thrombosis This can present acutely especially with stents are placed across arterio-venous junctions in AVG or when placed in central veins.…”

The Role of Endovascular Stents in Dialysis Access Maintenance

“…Cephalic arch stenosis (CAS) is a common cause of brachiocephalic arteriovenous fistula (AVF) dysfunction 20 . The use of various types of stents as a treatment of cephalic arch stenosis has been reported 21 .…”

“…Secondary fistulas constitute an excellent option for patients with failing AVGs with excellent primary and secondary patency rates 32 . The high cost of stents is another factor of consideration, raising concern into whether the benefits obtained by placing stents at VGA stenosis sites outweigh the costs associated with such treatment 20 . Careful thought should be given to the option of creating a secondary AVF as an alternative treatment to placing a stent at a VGA stenosis site.…”