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Pisano U, Stevenson K, Kasthuri R, Kingsmore D. Cephalic arch stenosis: an analysis of outcome by type of first intervention. CVIR Endovasc 2024; 7:13. [PMID: 38240913 PMCID: PMC10798936 DOI: 10.1186/s42155-023-00424-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 12/21/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Cephalic arch stenoses (CAS) occur in near 70% of elbow arteriovenous fistulas. Percutaneous transluminal angioplasty (PTA) remains first-line treatment despite documented stent-grafts (SG) efficacy. The study aim is to report long-term outcomes based on initial treatment of CAS. METHODS Retrospective review of 12-year data in single tertiary centre. Outcomes included technical success, rupture rate, primary patency (PP), dialysis performance; categorical variables assessed via χ2 or Fisher's; nonparametric tests used for skewed data. Kaplan-Meier analysis used for PP and cumulative patency. Cox proportional hazard regression model to assess explanatory variables in PP. RESULTS One hundred one brachio- and radiocephalic fistulas with CAS were included. SG as first intervention had higher success than PTA (85% vs 61%, p = 0.003). Rupture occurred in 9/85 (10.6%) PTA vs 0% in SG (p = 0.046). In a subgroup with poor urea reduction rate (URR), both PTA and SG improved dialysis performance post-intervention (p = 0.002). SG demonstrated better PP than PTA (79,73,60% patency at 3, 6, 9 months; versus 71,51,47%; p = 0.195) and cumulative patency (73,61,61% at 1, 2, 3 years; versus 60,34,26%; p < 0.001). Of the variables analyzed, technical success of PTA was the only discriminating factor (coeff.-1.01; RR 35%, p = 0.035). Accesses that underwent secondary stenting performed better than primarily stented CAS (p = 0.01). CONCLUSIONS SG superiority is confirmed in CAS, particularly when angioplasty is unsuccessful. While PTA has short-lived benefits, it can improve dialysis performance. Other than higher success rate, primary CAS stenting did not have advantages compared to post-PTA stenting in our study. Other factors related to inflow, outflow, conduit characteristics are presumed to be involved in access longevity.
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Affiliation(s)
- Umberto Pisano
- Radiology Department, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, 1345 Govan Road, Glasgow, G51 4TF, UK.
| | - Karen Stevenson
- Renal Transplant Surgery, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, 1345 Govan Road, Glasgow, G51 4TF, UK
| | - Ram Kasthuri
- Radiology Department, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, 1345 Govan Road, Glasgow, G51 4TF, UK
| | - David Kingsmore
- Renal Transplant Surgery, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, 1345 Govan Road, Glasgow, G51 4TF, UK
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Murakami M, Furushima D, Hamamoto S, Yamada H, Okawa T, Tanaka S, Nagai K. Comparison of peripheral cutting balloon angioplasty with conventional balloon angioplasty for recurrent hemodialysis vascular access stenosis: A prospective randomized controlled trial. J Vasc Access 2023:11297298231209489. [PMID: 37997018 DOI: 10.1177/11297298231209489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023] Open
Abstract
PURPOSE This study aimed to compare the efficacy and safety of cutting balloon angioplasty (CBA) and conventional balloon angioplasty (control group) for recurrent vascular access stenosis in arteriovenous fistulas. MATERIALS AND METHODS This prospective, randomized single-center clinical trial included patients with hemodynamically significant recurrent vascular access stenosis of an arteriovenous fistula. The Kaplan-Meier method was used to assess primary patency, whereas the log-rank test was used to evaluate differences in patency between groups. Functional evaluations were performed using Doppler ultrasonography. RESULTS Patients (n = 122) were randomly assigned to undergo CBA or conventional balloon angioplasty between December 2012 and November 2017. The clinical success rate was 100% in both groups. The anatomical success rates were 65% and 56% in the CBA and control groups, respectively. The primary patency of the target lesion was significantly better in the CBA group (33.3%) than in the control group (16.1%) at 6 months (hazard ratio, 0.50; 95% confidence interval, 0.33-0.77; p = 0.00171). The stenosis percentage decreased significantly after angioplasty in the CBA group (Δ-50.7%) compared with the control group (Δ-41.9%) (p = 0.0008). Access flow, measured using duplex Doppler ultrasonography, improved after angioplasty in both groups (300-526 ml/min in the control group and, 268-546 ml/min in the CBA group). Change in access flow (Δ + 278 ± 162) in the CBA group tended to be greater than that in the control group (Δ + 226 ± 151) (p = 0.07). However, the difference was not statistically significant. CONCLUSION In patients with recurrent vascular access stenosis of the arteriovenous fistula CBA is effective and superior to conventional angioplasty.
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Affiliation(s)
- Masaaki Murakami
- Department of Nephrology, Shizuoka General Hospital, Shizuoka, Japan
| | - Daisuke Furushima
- School of Health Science, Faculty of Medicine, Kagoshima University, Kagoshima, Japan
| | - Shingo Hamamoto
- Department of Drug Evaluation and Informatics, School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
| | - Hiroshi Yamada
- Department of Drug Evaluation and Informatics, School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan
| | - Takao Okawa
- Department of Nephrology, Shizuoka General Hospital, Shizuoka, Japan
| | - Satoshi Tanaka
- Department of Nephrology, Shizuoka General Hospital, Shizuoka, Japan
| | - Kojiro Nagai
- Department of Nephrology, Shizuoka General Hospital, Shizuoka, Japan
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3
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Kim JH, Lee HS, Kwon MJ, Song YR, Kim SG, Kim JK. Role of neutrophil extracellular traps in vascular access thrombosis in hemodialysis patients. Thromb Res 2023; 231:121-127. [PMID: 37857225 DOI: 10.1016/j.thromres.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/16/2023] [Accepted: 10/10/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND A patent vascular access (VA) is a lifeline for hemodialysis (HD) patients. However, vascular access is prone to thrombosis, which, if left untreated, can lead to permanent VA loss and increased mortality. Neutrophil extracellular traps (NETs) are known to be involved in intravascular thrombosis. We evaluated the relationship between NETs and VA thrombosis and their impact on VA prognosis. METHODS A total of 189 patients with VA flow problems were enrolled. Among these, 93 patients underwent percutaneous transluminal angioplasty (PTA) for stenosis, and 96 patients underwent PTA with thrombectomy for thrombosis. Plasma nucleosome, myeloperoxidase-DNA complex, and von Willebrand factor (vWF) were measured as markers of circulating NETs and thrombosis risk, respectively. The primary outcome was permanent VA loss and the secondary outcome was recurrent thrombotic occlusion within 6 months. In addition, the presence of NETs in thrombi was evaluated by histopathological analysis. RESULTS Circulating nucleosome levels were closely associated with plasma vWF levels (r = 0.172, p = 0.025), and both were higher in thrombectomy cases than in PTA alone cases (nucleosome; 0.83 ± 0.70 vs. 0.35 ± 0.26, p < 0.001, vWF: 9.0 ± 7.6 vs. 7.3 ± 6.2, p = 0.038). The highest quartile of nucleosomes (Q4) was associated with an 18-fold increased rate of access thrombotic occlusion (p < 0.001). In addition, multivariate analysis showed that the rates of permanent access loss (HR 2.77, 95 % CI 1.35-5.77) and recurrent thrombosis (HR 2.35, 95 % CI 1.22-4.54) were much higher in patients with the Q4 nucleosome group than in those with Q1-3. In addition, higher neutrophil infiltration and NET expression in thrombi were also associated with poor VA prognosis. CONCLUSIONS Higher levels of circulating NETs and the amount of NET expression in thrombi may be associated with VA thrombosis and poor VA outcomes.
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Affiliation(s)
- Ji Hwan Kim
- Department of Internal Medicine & Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Hyung Seok Lee
- Department of Internal Medicine & Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Mi Jung Kwon
- Department of Pathology, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Young Rim Song
- Department of Internal Medicine & Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Sung Gyun Kim
- Department of Internal Medicine & Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Jwa-Kyung Kim
- Department of Internal Medicine & Kidney Research Institute, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea.
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Ratnam L, Karunanithy N, Mailli L, Diamantopoulos A, Morgan RA. Dialysis Access Maintenance: Plain Balloon Angioplasty. Cardiovasc Intervent Radiol 2023; 46:1136-1143. [PMID: 37156943 PMCID: PMC10471649 DOI: 10.1007/s00270-023-03441-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/31/2023] [Indexed: 05/10/2023]
Abstract
Plain balloon angioplasty remains the first-line treatment for dialysis access stenosis. This chapter reviews the outcomes of plain balloon angioplasty from cohort studies and comparative studies. Angioplasty outcomes are more favourable in arteriovenous fistulae (AVF) compared to arteriovenous grafts (AVG) with primary patency at 6 months ranging from 42-63% compared to 27-61%, respectively, and improved for forearm fistulae compared with upper arm fistulae. Higher pressures are required to treat stenoses in AVFs compared to AVGs. Outcomes are worse in more severe stenoses, increased patient age, previous interventions and fistulae that develop early stenoses. Major complication rates following angioplasty in dialysis access are between 3 and 5%. Repeat treatments and the use of adjuncts such as drug-coated balloons and stents can prolong the patency of dialysis access. Level of Evidence No level of evidence (Review paper).
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Affiliation(s)
- Lakshmi Ratnam
- Department of Interventional Radiology, St George's University Hospitals NHS Foundation Trust, London, UK.
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK.
| | - Narayan Karunanithy
- Department of Interventional Radiology, Guys and St. Thomas NHS Foundation Trust, London, UK
- School of Biomedical Engineering & Imaging Sciences, Faculty of Life Sciences & Medicine, Kings College London, London, UK
| | - Leto Mailli
- Department of Interventional Radiology, St George's University Hospitals NHS Foundation Trust, London, UK
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK
| | - Athanasios Diamantopoulos
- Department of Interventional Radiology, Guys and St. Thomas NHS Foundation Trust, London, UK
- School of Biomedical Engineering & Imaging Sciences, Faculty of Life Sciences & Medicine, Kings College London, London, UK
| | - Robert A Morgan
- Department of Interventional Radiology, St George's University Hospitals NHS Foundation Trust, London, UK
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK
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Allon M, Al-Balas A, Young CJ, Cutter GR, Lee T. Effects of a More Selective Arteriovenous Fistula Strategy on Vascular Access Outcomes. J Am Soc Nephrol 2023; 34:1589-1600. [PMID: 37401775 PMCID: PMC10482060 DOI: 10.1681/asn.0000000000000174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/31/2023] [Indexed: 07/05/2023] Open
Abstract
SIGNIFICANCE STATEMENT The optimal choice of vascular access for patients undergoing hemodialysis-arteriovenous fistula (AVF) or arteriovenous graft (AVG)-remains controversial. In a pragmatic observational study of 692 patients, the authors found that among patients who initiated hemodialysis with a central vein catheter (CVC), a strategy that maximized AVF placement resulted in a higher frequency of access procedures and greater access management costs for patients who initially received an AVF than an AVG. A more selective policy that avoided AVF placement if an AVF was predicted to be at high risk of failure resulted in a lower frequency of access procedures and access costs in patients receiving an AVF versus an AVG. These findings suggest that clinicians should be more selective in placing AVFs because this approach improves vascular access outcomes. BACKGROUND The optimal choice of initial vascular access-arteriovenous fistula (AVF) or graft (AVG)-remains controversial, particularly in patients initiating hemodialysis with a central venous catheter (CVC). METHODS In a pragmatic observational study of patients who initiated hemodialysis with a CVC and subsequently received an AVF or AVG, we compared a less selective vascular access strategy of maximizing AVF creation (period 1; 408 patients in 2004 through 2012) with a more selective policy of avoiding AVF creation if failure was likely (period 2; 284 patients in 2013 through 2019). Prespecified end points included frequency of vascular access procedures, access management costs, and duration of catheter dependence. We also compared access outcomes in all patients with an initial AVF or AVG in the two periods. RESULTS An initial AVG placement was significantly more common in period 2 (41%) versus period 1 (28%). Frequency of all access procedures per 100 patient-years was significantly higher in patients with an initial AVF than an AVG in period 1 and lower in period 2. Median annual access management costs were significantly higher among patients with AVF ($10,642) versus patients with AVG ($6810) in period 1 but significantly lower in period 2 ($5481 versus $8253, respectively). Years of catheter dependence per 100 patient-years was three-fold higher in patients with AVF versus patients with AVG in period 1 (23.3 versus 8.1, respectively), but only 30% higher in period 2 (20.8 versus 16.0, respectively). When all patients were aggregated, the median annual access management cost was significantly lower in period 2 ($6757) than in period 1 ($9781). CONCLUSIONS A more selective approach to AVF placement reduces frequency of vascular access procedures and cost of access management.
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Affiliation(s)
- Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alian Al-Balas
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Carlton J. Young
- Division of Transplant Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gary R. Cutter
- Department of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Timmy Lee
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
- Veterans Affairs Medical Center, University of Alabama at Birmingham, Birmingham, Alabama
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Shaikh A, Albalas A, Desiraju B, Dwyer A, Haddad N, Almehmi A. The role of stents in hemodialysis vascular access. J Vasc Access 2023; 24:107-116. [PMID: 33993804 PMCID: PMC10896277 DOI: 10.1177/11297298211015069] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Vascular access is the Achilles' heel of dialysis therapy among patient with end stage kidney disease. The development of neointimal hyperplasia and subsequent stenosis is common in vascular access and is associated with significant morbidity. Percutaneous transluminal angioplasty using balloon inflation was the standard therapy of these lesions. However, the balloon-based approaches were associated with poor vascular access patency rate necessitating new inventions. It is within this context that different types of stents were developed in order to improve the overall dialysis vascular access functionality. In this article, we review the available literature regarding the use of stents in treating dialysis vascular access stenotic lesions. Further, we review the major clinical trials of stent use in different anatomic locations and in different clinical scenarios.
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Affiliation(s)
- Aisha Shaikh
- Department of Medicine, James J. Peters VA Medical Center, Bronx, NY, USA
| | - Alian Albalas
- Department of Biology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Brinda Desiraju
- Department of Medicine, SUNY Downstate School of Medicine, Brooklyn, NY, USA
| | - Amy Dwyer
- Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Nabil Haddad
- Department of Medicine, The Ohio State University Medical Center, Columbus, OH, USA
| | - Ammar Almehmi
- Department of Medicine and Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
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Matsuoka Y, Iida O, Suemitsu K, Oka K, Ota N, Izumi M. Use of a fluoropolymer-based paclitaxel-eluting stent for arteriovenous graft outflow vein stenosis in hemodialysis patients. J Vasc Surg Cases Innov Tech 2021; 7:326-331. [PMID: 34041421 PMCID: PMC8144112 DOI: 10.1016/j.jvscit.2021.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 03/25/2021] [Indexed: 11/04/2022] Open
Abstract
We implanted a fluoropolymer-based paclitaxel-eluting stent (FP-PES) in four hemodialysis patients with refractory outflow venous stenosis of their arteriovenous graft. The mean observation period after FP-PES implantation was 11.5 ± 4.7 months (range, 7.0-18.0 months). After FP-PES implantation, the patients were evaluated by ultrasound every 3 months. No of the patients experienced neointimal hyperplasia in the stents during the observation period, and no reintervention was performed. FP-PESs could be an attractive alternative to percutaneous transluminal angioplasty for patients with refractory outflow venous stenosis of arteriovenous hemodialysis grafts.
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Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, Allon M, Asif A, Astor BC, Glickman MH, Graham J, Moist LM, Rajan DK, Roberts C, Vachharajani TJ, Valentini RP. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis 2020; 75:S1-S164. [PMID: 32778223 DOI: 10.1053/j.ajkd.2019.12.001] [Citation(s) in RCA: 877] [Impact Index Per Article: 219.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 12/09/2019] [Indexed: 02/07/2023]
Abstract
The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.
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A randomized feasibility study of the effect of ascorbic acid on post-angioplasty restenosis of hemodialysis vascular access (NCT03524846). Sci Rep 2019; 9:11095. [PMID: 31366980 PMCID: PMC6668477 DOI: 10.1038/s41598-019-47583-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 07/16/2019] [Indexed: 12/16/2022] Open
Abstract
Restenosis remains a significant problem after angioplasty of hemodialysis vascular access. Both experimental and clinical studies have shown a protective effect of antioxidants against post-angioplasty restenosis. A prospective, randomized, feasibility study was conducted to investigate the effect of ascorbic acid to prevent restenosis. Ninety-three hemodialysis patients were randomized into three groups after angioplasty: placebo (n = 31), 300 mg ascorbic acid (n = 31), and 600 mg ascorbic acid (n = 31), treated intravenously 3 times per week for 3 months. Eighty-nine completed the clinical follow-up, and 81 had angiographic follow-up. In the angiographic follow-up, the mean (stand deviation) late loss of luminal diameter for the placebo, 300 mg, and 600 mg groups were 3.15 (1.68) mm, 2.52 (1.70) mm (P = 0.39 vs. placebo group), and 1.59 (1.67) mm (P = 0.006, vs. placebo group), with corresponding angiographic binary restenosis of 79%, 67% (P = 0.38 vs. placebo group), and 54% (P = 0.08 vs. placebo group). The post-interventional primary patency rates at 3 months were 47%, 55% (P = 0.59 vs. placebo group), and 70% (P = 0.18 vs. placebo group) for placebo, 300 mg, and 600 mg groups. Our results demonstrated that intravenous 600 mg ascorbic acid was a feasible therapy and might attenuate restenosis after angioplasty; however, its effect on post-interventional primary patency was modest.
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Thrombophilia Associated with Early Post-angioplasty Thrombosis of Dialysis Vascular Access. Cardiovasc Intervent Radiol 2018; 41:1683-1690. [PMID: 30066093 DOI: 10.1007/s00270-018-2046-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022]
Abstract
AIM Percutaneous transluminal angioplasty (PTA) is widely used as the primary treatment for dialysis vascular access dysfunction. Nonetheless, many patients develop early occlusion after angioplasty. Thus, we investigated the role of thrombophilia in access occlusion within 30 days of angioplasty. MATERIALS AND METHODS This case-control study included patients who underwent PTA for dialysis vascular access dysfunction. Patients who experienced occlusion within 30 days of angioplasty were included in the case group and those without occlusion for at least 30 days after angioplasty were included in the control group. All patients were tested for protein C, protein S, antithrombin III, lupus anticoagulant, and anticardiolipin antibodies. RESULTS From February to October 2015, 462 patients underwent PTA for dialysis vascular access dysfunction. Forty-one patients (8.9%) had early occlusion within 30 days of angioplasty. The case group had more graft accesses (73 vs. 31%, P < 0.001) and thrombotic occlusions (67 vs. 15%, P < 0.001). A higher incidence of protein C (10 vs. 2%), protein S (15 vs. 5%), and antithrombin III (10 vs. 2%) deficiency and elevated anticardiolipin antibody (22 vs. 10%) levels were observed in the case group. Overall, 26 patients (63%) in the case group had at least one thrombophilic factor, compared with 15 patients (37%) in the control group (unadjusted odds ratio [OR], 3.004; 95% confidence interval [CI], 1.223-7.380; P = 0.027). After adjustment for confounding factors, the association between thrombophilic factors and early occlusion remained (adjusted OR, 3.806; 95% CI, 1.018-14.220; P = 0.047). CONCLUSION Thrombophilia is associated with early occlusion after angioplasty for hemodialysis vascular access.
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Abstract
Stents are ubiquitously utilized in coronary and peripheral arterial disease. Interventional nephrologists, however, place stents in the venous outflow of the arteriovenous access. Stenosis is the predominant pathology that causes access dysfunction and will ultimately lead to thrombosis if uncorrected. Angioplasty and stent deployment are the current techniques available to combat stenosis. From initial bare metal stainless steel stents, the current generations of stents used are predominately covered nitinol stents. The latest randomized control trials reveal that stents decrease the number of interventions required to maintain patency but do not improve the overall access survival. Furthermore, bare metal stents have been shown to be inferior to stent grafts. This review discusses indications for stent deployment in the hemodialysis access, the current evidence for their use, and briefly touches on their complications.
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Affiliation(s)
- Kenneth Abreo
- School of Medicine, LSU Health Shreveport, Shreveport, LA, USA
| | - Adrian Sequeira
- School of Medicine, LSU Health Shreveport, Shreveport, LA, USA
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12
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Beathard GA, Lok CE, Glickman MH, Al-Jaishi AA, Bednarski D, Cull DL, Lawson JH, Lee TC, Niyyar VD, Syracuse D, Trerotola SO, Roy-Chaudhury P, Shenoy S, Underwood M, Wasse H, Woo K, Yuo TH, Huber TS. Definitions and End Points for Interventional Studies for Arteriovenous Dialysis Access. Clin J Am Soc Nephrol 2018; 13:501-512. [PMID: 28729383 PMCID: PMC5967683 DOI: 10.2215/cjn.11531116] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This paper is part of the Clinical Trial Endpoints for Dialysis Vascular Access Project of the American Society of Nephrology Kidney Health Initiative. The purpose of this project is to promote research in vascular access by clarifying trial end points which would be best suited to inform decisions in those situations in which supportive clinical data are required. The focus of a portion of the project is directed toward arteriovenous access. There is a potential for interventional studies to be directed toward any of the events that may be associated with an arteriovenous access' evolution throughout its life cycle, which has been divided into five distinct phases. Each one of these has the potential for relatively unique problems. The first three of these correspond to three distinct stages of arteriovenous access development, each one of which has been characterized by objective direct and/or indirect criteria. These are characterized as: stage 1-patent arteriovenous access, stage 2-physiologically mature arteriovenous access, and stage 3-clinically functional arteriovenous access. Once the requirements of a stage 3-clinically functional arteriovenous access have been met, the fourth phase of its life cycle begins. This is the phase of sustained clinical use from which the arteriovenous access may move back and forth between it and the fifth phase, dysfunction. From this phase of its life cycle, the arteriovenous access requires a maintenance procedure to preserve or restore sustained clinical use. Using these definitions, clinical trial end points appropriate to the various phases that characterize the evolution of the arteriovenous access life cycle have been identified. It is anticipated that by using these definitions and potential end points, clinical trials can be designed that more closely correlate with the goals of the intervention and provide appropriate supportive data for clinical, regulatory, and coverage decisions.
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Affiliation(s)
- Gerald A Beathard
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Thomas M, Nesbitt C, Ghouri M, Hansrani M. Maintenance of Hemodialysis Vascular Access and Prevention of Access Dysfunction: A Review. Ann Vasc Surg 2017; 43:318-327. [DOI: 10.1016/j.avsg.2017.02.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 02/28/2017] [Indexed: 01/24/2023]
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14
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Pietryga JA, Little MD, Robbin ML. Sonography of Arteriovenous Fistulas and Grafts. Semin Dial 2017; 30:309-318. [PMID: 28393400 DOI: 10.1111/sdi.12599] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) are the vascular accesses of choice for long-term hemodialysis. Strategies to establish and maintain functioning AVFs and AVGs are essential. In addition to clinical evaluation, ultrasound plays a critical role in the evaluation and maintenance of AVFs and AVGs. AVFs have a high rate of failure to mature which can be reliably diagnosed with ultrasound. Treatable etiologies of the failure to mature can often be diagnosed with ultrasound. Causes of secondary AVG failure can also be diagnosed with ultrasound and treated. AVGs have a relatively short functional life expectancy due to a high rate of AVG thrombosis. Ultrasound is a safe, noninvasive way to diagnose vascular stenosis in both AVFs and AVGs prior to thrombosis, potentially saving the access. Routine surveillance ultrasound of asymptomatic AVFs and AVGs is controversial with conflicting studies on its benefit. Routine surveillance ultrasound of AVFs and AVGs is not common practice.
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Affiliation(s)
- Jason A Pietryga
- The Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mark D Little
- The Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michelle L Robbin
- The Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
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Wu CC, Hung SC, Kuo KL, Tarng DC. Impact of Indoxyl Sulfate on Progenitor Cell-Related Neovascularization of Peripheral Arterial Disease and Post-Angioplasty Thrombosis of Dialysis Vascular Access. Toxins (Basel) 2017; 9:E25. [PMID: 28067862 PMCID: PMC5308257 DOI: 10.3390/toxins9010025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 12/28/2016] [Accepted: 01/04/2017] [Indexed: 01/09/2023] Open
Abstract
Patients with chronic kidney disease (CKD) have an increased risk of vascular disease, which is associated with considerable health care costs. Vascular disease in CKD differs clinically and pathobiologically from that in patients with normal renal function. Besides the traditional risk factors, retention of uremic toxins contributes to the pathogenesis of vascular disease in patients with CKD. Indoxyl sulfate is a protein-bound uremic toxin and is inefficiently removed by conventional dialysis. Accumulating evidence suggests that indoxyl sulfate is a vascular toxin involved in atherosclerosis, arteriosclerosis, vascular calcification and vascular repair. Clinically, indoxyl sulfate is associated with total and cardiovascular mortality in patients with CKD. Recent studies have indicated that in addition to coronary and cerebral arteries, indoxyl sulfate plays a role in peripheral artery disease (PAD) and dialysis graft thrombosis. Emerging evidence suggests that indoxyl sulfate is implicated via novel mechanisms, including progenitor cell-related neovascularization and tissue factor-related hypercoagulability. These findings raise the possibility that strategies targeting serum indoxyl sulfate may have the potential to improve the outcomes of PAD and dialysis vascular access in patients with CKD.
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Affiliation(s)
- Chih-Cheng Wu
- Cardiovascular Center, National Taiwan University Hospital, Hsinchu Branch, Hsinchu 30059, Taiwan.
- National Tsing-Hua University, Institute of Biomedical Engineering, Hsinchu 30013, Taiwan.
- School of Medicine, National Yang-Ming University, Taipei 11217, Taiwan.
| | - Szu-Chun Hung
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, Hualien 97004, Taiwan.
| | - Ko-Lin Kuo
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and School of Medicine, Tzu Chi University, Hualien 97004, Taiwan.
| | - Der-Cherng Tarng
- Institutes of Physiology and Clinical Medicine, National Yang-Ming University, Taipei 11217, Taiwan.
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan.
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El Kassem M, Alghamdi I, Vazquez-Padron RI, Asif A, Lenz O, Sanjar T, Fayad F, Salman L. The Role of Endovascular Stents in Dialysis Access Maintenance. Adv Chronic Kidney Dis 2015; 22:453-8. [PMID: 26524950 DOI: 10.1053/j.ackd.2015.02.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 02/10/2015] [Indexed: 11/11/2022]
Abstract
Vascular stenosis is most often the culprit behind hemodialysis vascular access dysfunction, and although percutaneous transluminal angioplasty remains the gold standard treatment for vascular stenosis, over the past decade the use of stents as a treatment option has been on the rise. Aside from the 2 Food and Drug Administration-approved stent grafts for the treatment of venous graft anastomosis stenosis, use of all other stents in vascular access dysfunction is off-label. Kidney Disease Outcomes Quality Initiative recommends limiting stent use to specific conditions, such as elastic lesions and recurrent stenosis; otherwise, additional adapted indications are in procedure-related complications, such as grade 2 and 3 hematomas. Published reports have shown the potential use of stents in a variety of conditions leading to vascular access dysfunction, such as venous graft anastomosis stenosis, cephalic arch stenosis, central venous stenosis, dialysis access aneurysmal elimination, cardiac implantable electronic device-induced stenosis, and thrombosed arteriovenous grafts. Although further research is needed for many of these conditions, evidence for recommendations has been clear in some; for instance, we know now that stents should be avoided along cannulation sites and should not be used in eliminating dialysis access aneurysms. In this review article, we evaluate the available evidence for the use of stents in each of the aforementioned conditions leading to hemodialysis vascular access dysfunctions.
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Wu CC, Hsieh MY, Hung SC, Kuo KL, Tsai TH, Lai CL, Chen JW, Lin SJ, Huang PH, Tarng DC. Serum Indoxyl Sulfate Associates with Postangioplasty Thrombosis of Dialysis Grafts. J Am Soc Nephrol 2015; 27:1254-64. [PMID: 26453609 DOI: 10.1681/asn.2015010068] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 07/15/2015] [Indexed: 01/07/2023] Open
Abstract
Hemodialysis vascular accesses are prone to recurrent stenosis and thrombosis after endovascular interventions.In vitro data suggest that indoxyl sulfate, a protein-bound uremic toxin, may induce vascular dysfunction and thrombosis. However, there is no clinical evidence regarding the role of indoxyl sulfate in hemodialysis vascular access. From January 2010 to June 2013, we prospectively enrolled patients undergoing angioplasty for dialysis access dysfunction. Patients were stratified into tertiles by baseline serum indoxyl sulfate levels. Study participants received clinical follow-up at 6-month intervals until June 2014. Primary end points were restenosis, thrombosis, and failure of vascular access. Median follow-up duration was 32 months. Of the 306 patients enrolled, 262 (86%) had symptomatic restenosis, 153 (50%) had access thrombosis, and 25 (8%) had access failure. In patients with graft access, free indoxyl sulfate tertiles showed a negative association with thrombosis-free patency (thrombosis-free patency rates of 54%, 38%, and 26% for low, middle, and high tertiles, respectively;P=0.001). Patients with graft thrombosis had higher free and total indoxyl sulfate levels. Using multivariate Cox regression analysis, graft thrombosis was independently predicted by absolute levels of free indoxyl sulfate (hazard ratio=1.14;P=0.01) and free indoxyl sulfate tertiles (high versus low, hazard ratio=2.41;P=0.001). Results of this study provide translational evidence that serum indoxyl sulfate is a novel risk factor for dialysis graft thrombosis after endovascular interventions.
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Affiliation(s)
- Chih-Cheng Wu
- Cardiovascular Center and Institute of Biomedical Engineering, National Tsing-Hua University, Taipei, Taiwan; College of Medicine and School of Medicine
| | | | - Szu-Chun Hung
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan; Buddhist Tzu Chi University, Hualien, Taiwan
| | - Ko-Lin Kuo
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan; Buddhist Tzu Chi University, Hualien, Taiwan
| | | | - Chao-Lun Lai
- Emergency and Critical Care Center, National Taiwan University Hospital, Hsinchu Branch, Taipei, Taiwan; Cardiovascular Research Center, and
| | - Jaw-Wen Chen
- Department of Medical Research and Institute and Department of Pharmacology and Cardiovascular Research Center
| | - Shing-Jong Lin
- Department of Medical Research and Institute of Clinical Medicine and Cardiovascular Research Center, Taipei Medical University, Taipei, Taiwan; and
| | - Po-Hsun Huang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital and Institute of Clinical Medicine, Taipei, Taiwan Cardiovascular Research Center, and
| | - Der-Cherng Tarng
- Institutes of Physiology and Clinical Medicine, Genome Research and Infection and Immunity Centers, National Yang-Ming University, Taipei, Taiwan; Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan;
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Yang YS, Han KD, Choi EH, Park YS, Seo YH, Kim CS. Clinical Experience with a Hybrid Procedure Using the Adherent Clot Catheter for Salvage of Thrombosed Hemodialysis Access: A Comparison with the Standard Fogarty Balloon Catheter. Vasc Specialist Int 2015. [PMID: 26217641 PMCID: PMC4480287 DOI: 10.5758/vsi.2015.31.1.25] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE This study aimed to compare the efficacy of two different catheters in hybrid surgery for salvage of thrombosed hemodialysis accesses. MATERIALS AND METHODS The hybrid salvage procedure (surgical thrombectomy followed by endovascular angioplasty) of the thrombosed hemodialysis access, was performed using adherent clot (AC) catheter in 140 cases and Fogarty balloon catheter in 68 cases. Procedure-related outcomes such as the clot removal status, clinical success, complications, and primary patency rates were analyzed retrospectively. RESULTS The proportion of cases with good clot removal scores in the AC catheter and Fogarty balloon catheter groups was 77.9% and 91.2%, respectively (P=0.018). Clinical success was achieved in 90.7% of the cases in the AC catheter group and in 98.5% of the cases in the balloon catheter group (P=0.035). The mean patency rates of the two groups were 50.7% and 63.2% at 3 months, 40.7% and 47.1% at 6 months, and 17.9% and 19.1% at 12 months. The complication rates (12.1% and 5.9%) and primary patency rates between the two catheters were not statistically different (P=0.328). On the analysis of the patency rate on access type of autologous (P=0.169) and prothetic graft (P=0.423), there was no significant difference between the two catheter groups. CONCLUSION In terms of clot removal and clinical success, the AC catheter did not demonstrate better outcomes than the Fogarty balloon catheter. However, primary patency was not related to the type of catheter. Adherent clot catheter can be a useful alternative to Fogarty balloon catheter for thrombosed hemodialysis access.
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Affiliation(s)
- Yu Sung Yang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Presbyterian Medical Center, University of Seonam College of Medicine, Jeonju, Korea
| | - Kyu Dam Han
- Division of Vascular and Endovascular Surgery, Department of Surgery, Presbyterian Medical Center, University of Seonam College of Medicine, Jeonju, Korea
| | - Eun Hye Choi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Presbyterian Medical Center, University of Seonam College of Medicine, Jeonju, Korea
| | - Young Sam Park
- Division of Vascular and Endovascular Surgery, Department of Surgery, Presbyterian Medical Center, University of Seonam College of Medicine, Jeonju, Korea
| | - Yeon Ho Seo
- Department of Chest Surgery, Presbyterian Medical Center, University of Seonam College of Medicine, Jeonju, Korea
| | - Cheol Seung Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Presbyterian Medical Center, University of Seonam College of Medicine, Jeonju, Korea
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Abstract
Arteriovenous grafts (AVGs) are prone to frequent thrombosis that is superimposed on underlying hemodynamically significant stenosis, most commonly at the graft-vein anastomosis. There has been great interest in detecting AVG stenosis in a timely fashion and performing preemptive angioplasty, in the belief that this will prevent AVG thrombosis. Three surveillance methods (static dialysis venous pressure, flow monitoring, and duplex ultrasound) can detect AVG stenosis. Whereas observational studies have reported that surveillance with preemptive angioplasty substantially reduces AVG thrombosis, randomized clinical trials have failed to confirm such a benefit. There is a high frequency of early AVG restenosis after angioplasty caused by aggressive neointimal hyperplasia resulting from vascular injury. Stent grafts prevent AVG restenosis better than balloon angioplasty, but they do not prevent AVG thrombosis. Several pharmacologic interventions to prevent AVG failure have been evaluated in randomized clinical trials. Anticoagulation or aspirin plus clopidogrel do not prevent AVG thrombosis, but increase hemorrhagic events. Treatment of hyperhomocysteinemia does not prevent AVG thrombosis. Dipyridamole plus aspirin modestly decreases AVG stenosis or thrombosis. Fish oil substantially decreases the frequency of AVG stenosis and thrombosis. In patients who have exhausted all options for vascular access in the upper extremities, thigh AVGs are a superior option to tunneled internal jugular vein central vein catheters (CVCs). An immediate-use AVG is a reasonable option in patients with recurrent CVC dysfunction or infection. Tunneled femoral CVCs have much worse survival than internal jugular CVCs.
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Affiliation(s)
- Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
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20
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Percutaneous Transluminal Angioplasty in Japan: Five-Center Investigation. J Vasc Access 2015; 16 Suppl 10:S38-42. [DOI: 10.5301/jva.5000426] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2015] [Indexed: 11/20/2022] Open
Abstract
Purpose Percutaneous transluminal angioplasty (PTA) is the first-line treatment for vascular access stenosis. To our knowledge, multicenter clinical research of PTA has not been reported in Japan. We examined the efficacy and safety of PTA for arteriovenous fistula (AVF) and arteriovenous graft (AVG) in five centers of Japan. Methods Three hundred cases of angioplasty for AVF and 300 for AVG were examined in three centers each. A hundred consecutive patients from each center who underwent PTA for AVG or AVF prior to March 2014 and met the inclusion criteria were searched retrospectively. Primary patency rates were estimated using the Kaplan-Meier method. Results The mean age was 69.3 ± 11.2 years in the AVF group and 70.2 ± 11.9 years in the AVG group. The anatomical success rates were 51.7% (155 of 300) in the AVF group and 72.0% (216 of 300) in the AVG group. The clinical success rates were 99.7% (299 of 300) in the AVF group and 100% (300 of 300) in the AVG group. A total of 25 complications (4.17%) were encountered in both groups including one major complication (0.17%). The primary patency was 99.0% at 1 month, 87.9% at 3 months and 51.7% at 6 months in the AVF group, and 96.0% at 1 month, 64.8% at 3 months and 20.4% at 6 months in the AVG group. Conclusions The clinical success rate of PTA in five centers was relatively high and a major complication rate was only 0.17%. However, anatomical success rates were low comparing with the previous studies and the primary patency rates were inferior to the past data.
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21
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Influence of drugs on arteriovenous vascular access dysfunction. J Vasc Access 2015; 16 Suppl 9:S61-5. [PMID: 25751553 DOI: 10.5301/jva.5000365] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2015] [Indexed: 01/04/2023] Open
Abstract
Vascular access dysfunction, due to venous stenosis at the vein-artery anastomosis in arteriovenous fistulas and vein-graft anastomosis in synthetic arteriovenous grafts, is a major cause of morbidity and mortality in dialysis patients. The two overarching approaches to prevent and treat vascular access dysfunction are from systemic or local (including endovascular and perivascular) routes. However, there are currently very few effective therapies to treat vascular access dysfunction. This article will review major studies evaluating systemic, endovascular, and perivascular therapies for vascular access dysfunction. Ongoing research to evaluate novel innovations to prevent and/or manage vascular access dysfunction appears promising.
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Oh E, Kim YJ, Goo DE, Yang S, Hong S. Percutaneous transluminal angioplasty for dysfunctional femoral hemodialysis graft. Diagn Interv Radiol 2015; 21:154-9. [PMID: 25644999 DOI: 10.5152/dir.2014.14231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to evaluate the safety and effectiveness of percutaneous transluminal angioplasty (PTA) for dysfunctional femoral arteriovenous graft and analyze clinical or anatomic predictors of graft patency. METHODS The records of 45 patients who underwent PTA or thromboaspiration for dysfunctional or thrombosed femoral arteriovenous graft from 2005 to 2012 were reviewed retrospectively. Primary and secondary patency rates were determined at three, six, and 12 months after PTA. The primary patency rate was analyzed according to the presence of diabetes mellitus, graft age from the time of creation to the first intervention (<12 months or ≥12 months), presence of thrombus, shape of graft (U-shape vs. straight-shape), anastomosis type of graft (femoral-femoral vs. femoral-saphenous), location of stenosis (central vs. peripheral), length of stenosis (<2 cm vs. ≥2 cm), degree of stenosis severity (<70% vs. ≥70%), and stent insertion. RESULTS A total of 124 PTAs were performed in 45 patients. The primary patency rate at three, six, and 12 months was 84.8%, 63.6%, and 24.2%, respectively. The secondary patency rate at three, six, and 12 months was 95.2%, 95.2%, and 85.7%, respectively. The mean duration of primary and secondary patency was 13.2 and 35.7 months, respectively. No significant clinical or anatomical predictors of primary patency could be identified. Stent placement had a negative effect on primary patency. CONCLUSION PTA is a safe and effective treatment for dysfunctional femoral arteriovenous grafts. Stent placement seems to improve technical success, but does not enhance the primary patency rate of dysfunctional femoral arteriovenous grafts.
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Affiliation(s)
- Eunsun Oh
- Department of Radiology, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea.
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23
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Rahmatzadeh M, Vijayan V, Ritter CJ, Hockley J, Leong BD, Sandford M, Mwipatayi BP. Transradial approach for challenging vascular access interventions. Vascular 2014; 23:374-81. [PMID: 25248384 DOI: 10.1177/1708538114546882] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Percutaneous interventional procedures for vascular access are usually performed using the draining cephalic or basilic vein. The transradial approach, which has been extensively investigated for coronary angiography and intervention, could be an attractive new technique for peri-anastomotic arteriovenous fistula stenosis. METHOD From June 2012 to February 2013, 30 patients with end-stage renal failure were evaluated for transradial vascular access intervention. A 4-French (Fr) micropuncture kit was used to access the radial artery and then subsequently upgraded to a 5-Fr sheath. Fourteen patients required an upgrade to a 6-Fr sheath for the final intervention. RESULTS Primary technical success (residual stenosis <30%) was achieved in all cases where angioplasty was performed. Technical success regarding access was achieved in all patients. There were no peri-procedural complications. The post-interventional primary patency was calculated as 100%, 100%, 88.4% and 32.8% at 1, 6, 9 and 12 months, respectively. The post-interventional primary assisted patency was calculated as 100%, 100%, 100% and 63.3% at 1, 6, 9 and 12 months, respectively. Based on colour-coded Duplex scan and/or photoelectric plethysmography, all access-site arteries showed normal perfusion; however, the freedom from significant radial artery restenosis was 92.4% at 12-month follow-up. CONCLUSION The transradial approach for vascular access endovascular interventions is technically feasible and safe. It allows simultaneous treatment of peri-anastomotic lesions in fistulas with complex venous anatomy as well as lesions in the arterial inflow and central outflow.
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Affiliation(s)
- Mitra Rahmatzadeh
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Australia
| | - Vikram Vijayan
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Australia
| | - Carsten J Ritter
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Australia
| | - Joseph Hockley
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Australia
| | - Benjamin Dk Leong
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Australia
| | - Monique Sandford
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Australia Renal Access Unit, Royal Perth Hospital, Perth, Australia
| | - Bibombe P Mwipatayi
- Department of Vascular Surgery, Royal Perth Hospital, Perth, Australia Renal Access Unit, Royal Perth Hospital, Perth, Australia School of Surgery, University of Western Australia, Australia
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The Eternal Tale of Dialysis Access Vessels and Restenosis: Are Drug-Eluting Balloons the Solution? J Vasc Access 2014; 15:439-47. [DOI: 10.5301/jva.5000271] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2014] [Indexed: 11/20/2022] Open
Abstract
In dialysis access fistulas and grafts, percutaneous transluminal angioplasty (PTA) is frequently followed by restenosis development, which results in repeated periodical re-interventions. The technique of drug-eluting balloon (DEB) angioplasty has shown promising results in the treatment of femoropopliteal arteriosclerotic lesions. In contrast to arteriosclerotic arteries, dialysis access vessels host unfavorable hemodynamics due to the direct conduction of high-pressure fluid into a low-pressure system. Hence, the beneficial effect of DEB angioplasty may be limited in this system. However, a first prospective randomized trial on 40 patients with arteriovenous fistula or graft stenoses exhibited a significantly higher 6-month primary patency of the treated lesions after DEB angioplasty than after uncoated balloon angioplasty. Despite such a positive reference, general recommendations regarding the value of DEBs in dialysis access vessels cannot be considered as serious unless large randomized controlled trials have been performed.
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Yan Y, Clark TWI, Mondschein JI, Shlansky-Goldberg RD, Dagli MS, Soulen MC, Stavropoulos SW, Sudheendra D, Mantell MP, Cohen RD, Kobrin S, Chittams JL, Trerotola SO. Outcomes of percutaneous interventions in transposed hemodialysis fistulas compared with nontransposed fistulas and grafts. J Vasc Interv Radiol 2014; 24:1765-72; quiz 1773. [PMID: 24409470 DOI: 10.1016/j.jvir.2013.08.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To compare postpercutaneous intervention outcomes of autogenous venous-transposition arteriovenous fistulas (AVFs) versus those of autogenous nontransposed AVFs (nAVFs) and prosthetic arteriovenous grafts (AVGs). MATERIALS AND METHODS A total of 591 hemodialysis accesses (195 transposed AVFs [tAVFs], 205 nAVFs, 191 AVGs) in 522 patients (278 male; mean age, 57 y; range, 15–91 y) underwent percutaneous transluminal angioplasty (PTA) and/or mechanical thrombectomy (ie, declotting). Access characteristics, surgical history, percutaneous interventions, postinterventional primary and secondary access patency, and follow-up data were collected. Cox proportional-hazards regression analyses, Fisher exact tests, and χ2 tests were performed. RESULTS Mean follow-up period was 32 months. Mean access ages at initial percutaneous intervention were 260 days (tAVF), 206 days (nAVF), and 176 days (AVG; P < .01). One-year postinterventional primary patency (PIPP) rates were 25% (tAVF), 24% (nAVF), and 14% (AVG). One-year postinterventional secondary patency (PISP) rates were 77% (tAVF), 61% (nAVF), and 63% (AVG). Median PIPP durations were 138 days (tAVF), 121 days (nAVF), and 79 days (AVG; P = .0001). Median PISP durations were 1,076 days (tAVF), 783 days (nAVF), and 750 days (AVG; P = .019). Total interventions needed to maintain PISP were 2.4 (tAVF), 1.3 (nAVF), and 3.2 (AVG) per patient-year (P < .001), which included 1.9, 1.2, and 1.4 PTAs (P < .01) and 0.45, 0.15, and 1.8 declotting procedures, respectively (P < .001). CONCLUSIONS Based on the number of percutaneous interventions needed to maintain PISP, these results confirm the current Dialysis Outcomes Quality Initiative access preference of nAVFs before tAVFs before AVGs. tAVFs offered superior postinterventional outcomes than AVGs. With additional interventions, tAVFs could even outperform nAVFs in terms of PISP.
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Which accesses should be abandoned or revised? J Vasc Access 2014; 15 Suppl 7:S76-80. [PMID: 24817460 DOI: 10.5301/jva.5000227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2014] [Indexed: 11/20/2022] Open
Abstract
This review considers the factors in deciding whether to abandon a functioning access. Strong indications for ligation or excision of an access are infection or severe early-onset steal. Access ligation may also be required for central vein occlusion or high-output cardiac failure. In general, a failing or thrombosed access should be restored to function unless it is no longer required. For failing or thrombosed distal arteriovenous fistulas, it may be easiest to abandon it and create a new fistula a few centimetres proximally rather than perform angioplasty, which is likely to require repeating. Other accesses may be abandoned after repeated treatment of the same stenosis over a short period provided other options exist.
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Ponce P, Carvalho T, Messias H, Neves F. Assessing the approach to a thrombosed AV graft. Semin Dial 2014; 27:518-21. [PMID: 24494710 DOI: 10.1111/sdi.12189] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The patency of the vascular access (VA) is a fight for the attending nephrologist. A retrospective observational study was conducted to compare the success rate of surgical versus endovascular technique percutaneous transluminal angioplasty (PTA) for graft thrombosis treatment. Of 3008 patients, 22.1% patients were dialyzed through grafts. Forty-five percent of all prevalent patients referred due to VA malfunction had a graft. For 18 months, 336 thrombosed grafts were submitted to surgery in 228 cases and to PTA in 126. PTA for thrombolysis included the Pharmaco-Mechanical Technique and the Arrow-Trerotola Device. Procedures were performed as outpatient, with an average delay of 1 day. Immediate success was 100% for surgery and 87.3% for PTA. The unassisted patency for thrombosed grafts for surgery/PTA was 265.12 ± 15.30/230.59 ± 19.83 days respectively, favoring surgery. The primary patency for thrombosed grafts treated by surgery/PTA at 30, 90, and 180 days was, respectively, 74.1%/81%, 63.2%/67.5%, and 53.9%/55.6% all in favor of PTA. AV grafts have a much higher rate of thrombosis than fistulas. Graft thrombosis can be dealt either by surgery or PTA, with identical success.
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Affiliation(s)
- Pedro Ponce
- Vascular Access Centre, NephroCare Portugal, Lisboa, Portugal
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28
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Chan MG, Miller FJ, Valji K, Bansal A, Kuo MD. Evaluating Patency Rates of an Ultralow-Porosity Expanded Polytetrafluoroethylene Covered Stent in the Treatment of Venous Stenosis in Arteriovenous Dialysis Circuits. J Vasc Interv Radiol 2014; 25:183-9. [DOI: 10.1016/j.jvir.2013.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2013] [Revised: 10/02/2013] [Accepted: 10/03/2013] [Indexed: 11/17/2022] Open
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29
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Ulloa JG, Kirkpatrick VE, Wilson SE, Williams RA. Stent salvage of arteriovenous fistulas and grafts. Vasc Endovascular Surg 2014; 48:234-8. [PMID: 24424661 DOI: 10.1177/1538574413518609] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study analyzes our experience using stents to salvage dysfunctional hemodialysis access sites at a single institution. METHODS We examined the outcomes of 42 consecutive patients who had covered (36 patients) or bare-metal (9 patients) stent intervention for hemodialysis access salvage. RESULTS Of our 42 male patients, 11 had stent salvage of an arteriovenous fistula, which yielded postintervention primary and secondary 6-month patencies of 27% and 55%, respectively. For 31 patients with arteriovenous grafts, the postintervention primary and secondary 6-month patencies were 26% and 29%, respectively. Patency rates were superior for stents placed in patent access sites, in fistulas compared to grafts, and when stents were placed in forearm sites although only the latter achieved statistical significance. CONCLUSIONS Stents can extend patency for the thrombosed or failing arteriovenous access, but results are poor once thrombosis has occurred. Stent placement appears to be more effective in fistulas compared to grafts.
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Affiliation(s)
- Jesus G Ulloa
- Veterans Administration Long Beach Healthcare System, Department of Surgery, Long Beach, CA, USA
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30
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Prologo JD, Minwell G, Kent J, Pirasteh A, Corn D. Effect of the time to intervention on the outcome of thrombosed dialysis access grafts managed percutaneously. Diagn Interv Radiol 2013; 20:143-6. [PMID: 24356296 DOI: 10.5152/dir.2013.13296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to investigate the effect of the time interval from the clinical presentation of a thrombosed dialysis access graft to intervention on procedure success. MATERIALS AND METHODS Records from two academic institutions for patients who underwent percutaneous thrombectomy of occluded surgical hemodialysis graft access sites in interventional radiology from 2006 to 2011 were reviewed retrospectively. The following data were recorded: gender, age, time and date of the initial request for a thrombectomy and the procedure, age of the surgical access, angiographic outcome, and clinical outcome (successful or unsuccessful postinterventional dialysis). Univariate and multivariate logistic regression were used to evaluate whether the time to intervention significantly affected the study endpoint. RESULTS In total, 268 percutaneous thrombectomies were performed in 139 patients. Of these 224 (83.5%) were categorized as successful and 44 (16.4%) as unsuccessful. The time to intervention was 19.9±30.1 vs. 22±35 hours for successful and unsuccessful procedures, respectively. The difference between the two was not significant, and there were also no significant differences in covariate distributions between successful and unsuccessful outcomes. CONCLUSION During the first 72 hours following clinical presentation of a thrombosed dialysis access graft, time to intervention may be considered independent of procedure outcome.
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Affiliation(s)
- John David Prologo
- From the Department of Radiology (J.D.P. e-mail: ), University Hospitals of Cleveland, Cleveland, Ohio, USA; The Division of Vascular and Interventional Radiology (J.D.P.), Urological Institute, Anesthesia Pain Management, and the National Center for Regenerative Medicine, and the Departments of Radiology (J.K., A.P.), and Biomedical Engineering (D.C.), University Hospitals Case Medical Center, Cleveland, Ohio, USA; the Department of Radiology (G.M.), Johns Hopkins Medical Center, Baltimore, Maryland, USA
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Translesional pressure ratio predicts technical outcome and patency in angioplasty on outflow stenosis of hemodialysis graft. J Vasc Access 2013; 15:264-71. [PMID: 24190070 DOI: 10.5301/jva.5000184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2013] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Translesional pressure ratio (TLPR) indicating fractional flow reserve has been applied to physiological assessment of moderate coronary stenosis. The role of TLPR in hemodialysis (HD) patients with arteriovenous graft (AVG) outflow stenosis undergoing percutaneous transluminal angioplasty (PTA) is unclear. The purpose of the study was to assess the validation of TLPR in such patients undergoing PTA. METHODS Patients with pure AVG outflow stenosis confirmed by angiography were prospectively enrolled. A TLPR defined as a ratio of the mean pressure downstream to the lesion(s) to the vein-sided intragraft pressure was measured using a catheter pullback method. Relationship among TLPR, angiographic result and clinical outcome within 6 months was detected. RESULTS Of 65 PTAs, the post-PTA TLPR significantly increased (from 0.28±0.10 to 0.50±0.11; p<0.0001). A significantly greater pre-PTA TLPR was observed in the simple lesions at baseline compared with the complex lesions (0.32±0.09 vs. 0.20±0.06; p<0.0001). Post-PTA TLPR ≥0.5 was powerfully related to angiographic success (p<0.0001). The group with angiographic success plus post-PTA TLPR ≥0.5 had a longer PTA-free patency (208.7±188.7 vs. 109.8±67.7 days; p=0.013) compared with that with angiographic nonsuccess plus post-PTA TLPR <0.5. CONCLUSIONS Our data show that TLPR correlates well with lesion properties and angiographic results, and helps predict following unassisted patency. The study suggests TLPR as a hemodynamic indicator during PTA.
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Chan MR, Shobande O, Vats H, Wakeen M, Meyer X, Bellingham J, Astor BC, Yevzlin AS. The effect of buttonhole cannulation vs. rope-ladder technique on hemodialysis access patency. Semin Dial 2013; 27:210-6. [PMID: 24118562 DOI: 10.1111/sdi.12143] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The rope-ladder (RL) technique is the most common technique used for cannulation of arteriovenous fistulae (AVF). Buttonhole cannulation (BHC), or constant-site technique, is recommended by the National Kidney Foundation's Kidney Disease Outcome Quality Initiative (NKF/KDOQI) vascular access guidelines. We compared outcomes of primary patency, episodes of bacteremia, access blood flow (Qa), and quality of life (QoL) scores between RL and BHC patients. Using a prospectively collected, vascular access database, a total of 45 prevalent dialysis patients using BHC were compared with 38 patients using the RL technique over a median of 12 months (inter-quartile range: 4-27 months). The two groups did not differ significantly in demographics except that diabetes was more common in those using BHC as compared to rope-ladder (69% vs. 34%; p = 0.002). Risk factors associated with lack of primary patency were age (hazards ratio [HR] = 1.02 per decade; 95% CI: 1.00-1.03; p = 0.04) and female gender (HR = 1.92; 95% CI: 1.08-3.40; p = 0.03). Use of the buttonhole technique was not associated with improved primary patency (HR = 1.22, 95% CI: 0.65-2.28; p = 0.53). Episodes of bacteremia and mean scores from KDQOL-36 did not differ significantly between the groups. This study demonstrates for the first time that BHC use is not associated with improved access patency.
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Affiliation(s)
- Micah R Chan
- Division of Nephrology, Department of Medicine, Madison, Wisconsin
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Kim JD, Bae JI, Won JH, Lee JH, Oh CK, Jung H, Lee HY. New Predictive Marker for Hemodialysis Vascular Access Dysfunction. Semin Dial 2013; 27:61-7. [PMID: 24028825 DOI: 10.1111/sdi.12137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ji Dae Kim
- Department of Radiology; Ajou University School of Medicine; Suwon Korea
| | - Jae Ik Bae
- Department of Radiology; Ajou University School of Medicine; Suwon Korea
| | - Je Hwan Won
- Department of Radiology; Ajou University School of Medicine; Suwon Korea
| | - Jong Hoon Lee
- Department of Surgery; Ajou University School of Medicine; Suwon Korea
| | - Chang-Kwon Oh
- Department of Surgery; Ajou University School of Medicine; Suwon Korea
| | - Hyuna Jung
- Department of Surgery; Ajou University School of Medicine; Suwon Korea
| | - Hyun Young Lee
- Clinical Trial Center; Ajou University School of Medicine; Suwon Korea
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Park HS, Kang SH, Chung BH, Choi BS, Park CW, Yang CW, Kim YS. Effect of intradialytic change in blood pressure and ultrafiltration volume on the variation in access flow measured by ultrasound dilution. Kidney Res Clin Pract 2013; 32:16-20. [PMID: 26889432 PMCID: PMC4716113 DOI: 10.1016/j.krcp.2012.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 09/29/2012] [Accepted: 10/09/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Prospective access flow measurement is the preferred method for vascular access surveillance in hemodialysis (HD) patients. We studied the effect of intradialytic change in blood pressure and ultrafiltration volume on the variation in access flow measured by ultrasound dilution. METHODS Access flow was measured 30 minutes, 120 minutes, and 240 minutes after the start of HD by ultrasound dilution in 30 patients during 89 HD sessions and evaluated for variation. RESULTS The mean age of the 30 patients was 62±11 years: 19 were male. The accesses comprised 16 fistulae and 14 grafts. The mean access flow over all sessions decreased by 6.1% over time (1265±568 mL/min after 30 minutes, 1260±599 mL/min after 120 minutes, and 1197±576 mL/min after 240 minutes, P<0.01 by repeated measures ANOVA). In addition, a≥5% decrease in mean arterial pressure during HD significantly reduced access flow (P=0.014). However, no other variable (ultrafiltration volume, sex, age, presence of diabetes, type or location of access, body surface area, hemoglobin, serum albumin level) interacted significantly with the effect of time on access flow. Furthermore, mean arterial pressure did not correlate with ultrafiltration volume. CONCLUSION We conclude that the variation in access flow during HD is relatively small. Decreased blood pressure is a risk factor for variation in access flow measured by ultrasound dilution. In most patients whose blood pressures are stable during HD, the access flow can be measured at any time during the HD treatment.
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Affiliation(s)
- Hoon Suk Park
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Seok Hui Kang
- Department of Internal Medicine, Yeungnam University Hospital, Daegu, Korea
| | - Byung Ha Chung
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Bum Soon Choi
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Cheol Whee Park
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Chul Woo Yang
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Yong-Soo Kim
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
- Corresponding author. Department of Internal Medicine, The Catholic University of Korea College of Medicine, 505 Banpo-dong, Seocho-gu, Seoul, 137-040, Korea.
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Hemodynamically significant arterial inflow stenosis in dysfunctional hemodialysis arteriovenous fistulae and grafts. J Vasc Access 2012; 13:452-8. [PMID: 22729525 DOI: 10.5301/jva.5000081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2012] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Hemodynamically significant arterial inflow stenosis in dysfunctional fistulae and grafts is poorly understood. No reliable clinical methods exist to detect arterial inflow stenosis. In this study, we assessed the accuracy of a novel screening method to detect arterial inflow stenosis in dysfunctional fistulae and grafts following successful juxta-anastomotic and venous outflow intervention. METHODS We prospectively evaluated all patients (N= 204) referred to our academic center for angiographic evaluation of a dysfunctional dialysis fistula/graft from May 1, 2006 to June 30, 2007. Following successful angioplasty/stenting of the venous outflow and juxta-anastomotic areas, patients were screened for arterial inflow stenosis. The screening method involved detection of 1) weak thrill, or sluggish blood flow on the post-intervention angiogram, 2) low mean arterial blood pressures in the dialysis access arm compared to the contralateral arm, and 3) inadequate blood flow at the first hemodialysis session post-intervention. If patients screened positive for any of these, they were further evaluated for arterial inflow stenosis. RESULTS Fifteen patients (15/204) were positive for arterial inflow stenosis on screening study. Eleven of those 15 had arterial stenosis on angiography, giving our screening method a positive predictive value of 73.3%. Eight patients were successfully treated by angioplasty/stenting. Two patients successfully underwent surgical intervention. Two year patency of revascularization was 91% (10/11). CONCLUSIONS Hemodynamically significant arterial inflow stenosis occurs and can be detected by simple clinical methods. Interventions for correction of the arterial inflow stenosis are successful.
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Outcomes of Prosthetic Hemodialysis Grafts after Deployment of Bare Metal versus Covered Stents at the Venous Anastomosis. Cardiovasc Intervent Radiol 2012; 35:832-8. [DOI: 10.1007/s00270-012-0413-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Accepted: 04/22/2012] [Indexed: 10/28/2022]
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Dolmatch BL, Duch JM, Winder R, Butler GM, Kershen M, Patel R, Trimmer CK, Lopera JE, Davidson IJ. Salvage of Angioplasty Failures and Complications in Hemodialysis Arteriovenous Access Using the FLUENCY Plus Stent Graft: Technical and 180-Day Patency Results. J Vasc Interv Radiol 2012; 23:479-87. [DOI: 10.1016/j.jvir.2011.12.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 12/21/2011] [Accepted: 12/26/2011] [Indexed: 10/28/2022] Open
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Affiliation(s)
- William L Whittier
- Department of Medicine, Division of Nephrology, Rush University Medical Center, Chicago, Illinois 60607, USA.
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Abstract
Hemodialysis vascular access surveillance continues to be widely recommended despite ongoing controversy as to its benefit in prolonging access patency compared with clinical monitoring alone. The most common screening tests are access blood flow and dialysis venous pressure measurements. When surveillance test results cross a predetermined threshold, accesses are referred for intervention with correction of stenosis to reduce future thrombosis and prolong access survival. Current surveillance strategies have four components: (1) underlying condition; (2) screening test; (3) intervention; and (4) outcomes. However, limitations exist within each component that may prevent achieving the desired outcomes. This review discusses these limitations and their consequences. To date, randomized controlled trials have not consistently shown that surveillance improves outcomes in grafts, and there is limited evidence that surveillance reduces thrombosis without prolonging the life of native fistulae. In conclusion, current evidence does not support the concept that all accesses should undergo routine surveillance with intervention.
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Affiliation(s)
- William D Paulson
- Charlie Norwood VA Medical Center and Nephrology Section, Department of Medicine, Georgia Health Sciences University, Augusta, Georgia, USA
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Abstract
A mature, functional arteriovenous (AV) access is the lifeline for a hemodialysis (HD) patient as it provides sufficient enough blood flow for adequate dialysis. As the chronic kidney disease (CKD) and end-stage renal disease (ESRD) population is expanding, and because of the well-recognized hazardous complications of dialysis catheters, the projected placement and use of AV accesses for HD is on the rise. Although a superior access than catheters, AV accesses are not without complications. The primary complication that causes AV accesses to fail is stenosis with subsequent thrombosis. Surveying for stenosis can be performed in a variety of ways. Clinical monitoring, measuring flow, determining pressure, and measuring recirculation are all methods that show promise. In addition, stenosis can be directly visualized, through noninvasive techniques such as color duplex imaging, or through minimally invasive venography. Each method of screening has its advantages and disadvantages, and several studies exist which attempt to answer the question of which test is the most useful. Ultimately, to maintain the functionality of the access for the HD patient, a team approach becomes imperative. The collaboration and cooperation of the patient, nephrologist, dialysis nurse and technician, vascular access coordinator, interventionalist, and vascular surgeon is necessary to preserve this lifeline.
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Affiliation(s)
- William L Whittier
- Department of Internal Medicine, Division of Nephrology, Rush University Medical Center, Chicago, Illinois
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Abstract
Vascular access monitoring can identify patients at increased risk of future access thrombosis. When coupled with a program of elective stenosis correction, access thrombosis rates decline approximately 50-75%. This results in arteriovenous (AV) fistula thrombosis rates of 0.1-0.2/patient year (vs. 0.2-0.4 at baseline) and AV graft thrombosis rates <0.5/patient year (vs. 0.8-1.2 thromboses/patient year at baseline). Evaluating the long-term impact on access survival remains problematic. There are no large-scale randomized trials and existing studies exhibit marked differences in target populations, clinical protocols and outcome definitions. Differences in payment systems also significantly influence the efficacy of monitoring and intervention programs. Despite these challenges, the current data support the K/DOQI recommendations that all patients undergo a program of regular access monitoring preferably by access flow measurement coupled with prompt imaging and elective stenosis correction for low flow accesses.
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Mudunuri V, O’Neal JC, Allon M. Thrombectomy of Arteriovenous Dialysis Grafts with Early Failure: Is it Worthwhile? Semin Dial 2010; 23:634-7. [DOI: 10.1111/j.1525-139x.2010.00799.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Purpose Endovascular stents have recently been shown to extend access patency in thrombosed and stenotic arteriovenous grafts. Given this improved patency, stent placement has outpaced balloon angioplasty in hemodialysis (HD) access interventions. However, concern remains over localized corrosion and increased neointimal hyperplasia of overlapping stents in the access circuit and whether this promotes premature stent failure. Methods This is a retrospective analysis of HD patients referred for access dysfunction during a 2-yr period. Using a prospectively collected, vascular access database, we identified 76 patients seen for follow-up angiography due to access dysfunction after stent placement. We compared the outcomes of overlapping vs. non-overlapping stents in measured primary assisted patency and mean percent luminal diameter as a marker of lesion severity. Results The two groups did not differ significantly in demographics or comorbid conditions. Only gender had a significant discrepancy between the two groups, with 65.5% vs. 42.9% male (p=0.01) in the overlapping vs. non-overlapping stent groups, respectively. The mean percent luminal stenosis was found to be 83.7 ± 17.3 and 85.5 ± 12.6 (p=0.55) for the overlapping vs. non-overlapping stent groups, respectively. For overlapping and non-overlapping stents, 30-day primary patency was 94% and 89%, respectively, 60-day primary patency was 77% and 63%, respectively, and 90-day primary patency was 68% and 50%, respectively. Using multiple regression analysis, no risk factors were identified to be associated with the severity of luminal stenosis. No identifiable risk factors were found to be associated with improved primary patency. In particular, overlapping vs. non-overlapping stents were not identified as a statistically significant factor influencing primary (assisted) patency (hazards ratio 0.60; 95% cI 0.34 to 1.06; p>0.05). Conclusions This study provides evidence that the theoretical concern of metal on metal corrosion and increased neointimal hyperplasia that can be seen with overlapping stents does not play a significant clinical role.
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Lai CC, Chung HM, Tsai HL, Mar GY, Tseng CJ, Liu CP. Intragraft pressures predict outcomes in hemodialysis patients with graft outflow lesions undergoing percutaneous transluminal angioplasty. Catheter Cardiovasc Interv 2010; 76:206-11. [DOI: 10.1002/ccd.22472] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Haskal ZJ, Trerotola S, Dolmatch B, Schuman E, Altman S, Mietling S, Berman S, McLennan G, Trimmer C, Ross J, Vesely T. Stent graft versus balloon angioplasty for failing dialysis-access grafts. N Engl J Med 2010; 362:494-503. [PMID: 20147715 DOI: 10.1056/nejmoa0902045] [Citation(s) in RCA: 283] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The leading cause of failure of a prosthetic arteriovenous hemodialysis-access graft is venous anastomotic stenosis. Balloon angioplasty, the first-line therapy, has a tendency to lead to subsequent recoil and restenosis; however, no other therapies have yet proved to be more effective. This study was designed to compare conventional balloon angioplasty with an expanded polytetrafluoroethylene endovascular stent graft for revision of venous anastomotic stenosis in failing hemodialysis grafts. METHODS We conducted a prospective, multicenter trial, randomly assigning 190 patients who were undergoing hemodialysis and who had a venous anastomotic stenosis to undergo either balloon angioplasty alone or balloon angioplasty plus placement of the stent graft. Primary end points included patency of the treatment area and patency of the entire vascular access circuit. RESULTS At 6 months, the incidence of patency of the treatment area was significantly greater in the stent-graft group than in the balloon-angioplasty group (51% vs. 23%, P<0.001), as was the incidence of patency of the access circuit (38% vs. 20%, P=0.008). In addition, the incidence of freedom from subsequent interventions at 6 months was significantly greater in the stent-graft group than in the balloon-angioplasty group (32% vs. 16%, P=0.03 by the log-rank test and P=0.04 by the Wilcoxon rank-sum test). The incidence of binary restenosis at 6 months was greater in the balloon-angioplasty group than in the stent-graft group (78% vs. 28%, P<0.001). The incidences of adverse events at 6 months were equivalent in the two treatment groups, with the exception of restenosis, which occurred more frequently in the balloon-angioplasty group (P<0.001). CONCLUSIONS In this study, percutaneous revision of venous anastomotic stenosis in patients with a prosthetic hemodialysis graft was improved with the use of a stent graft, which appears to provide longer-term and superior patency and freedom from repeat interventions than standard balloon angioplasty. (ClinicalTrials.gov number, NCT00678249.)
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Affiliation(s)
- Ziv J Haskal
- Division of Vascular and Interventional Radiology, University of Maryland Medical Center, 22 S. Greene St., GK214, Baltimore, MD 21201, USA.
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Bittl JA. Catheter Interventions for Hemodialysis Fistulas and Grafts. JACC Cardiovasc Interv 2010; 3:1-11. [DOI: 10.1016/j.jcin.2009.10.021] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Accepted: 10/05/2009] [Indexed: 11/26/2022]
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Yevzlin AS, Schoenkerman AB, Gimelli G, Asif A. Arterial Interventions in Arteriovenous Access and Chronic Kidney Disease: A Role for Interventional Nephrologists. Semin Dial 2009; 22:545-56. [DOI: 10.1111/j.1525-139x.2009.00626.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Most arteriovenous grafts fail due to irreversible thrombosis, and most clotted grafts have an underlying stenotic lesion. These observations raise the plausible hypothesis that early detection of graft stenosis with preemptive angioplasty will reduce the likelihood of graft thrombosis. A number of noninvasive methods can be used to detect hemodynamically significant graft stenosis with a high positive predictive value. These tests include clinical monitoring, as well as surveillance by static dialysis venous pressures, flow monitoring, or duplex ultrasound. However, these surveillance tests have a much lower positive predictive value for graft thrombosis in the absence of preemptive angioplasty. In other words, none of the currently available surveillance tests can reliably distinguish between stenosed grafts destined to clot, and those that will remain patent without intervention. As a consequence, any program of graft surveillance necessarily results in a substantial proportion of unnecessary angioplasties. Moreover, a substantial proportion of grafts thrombose despite a normal antecedent surveillance test. Numerous observational studies have found an impressive reduction of graft thrombosis after implementation of a stenosis surveillance program. In contrast, 5 of 6 randomized clinical trials failed to show a reduction of graft thrombosis in patients undergoing graft surveillance, as compared with those receiving only clinical monitoring. The lack of benefit of surveillance is largely attributable to the rapid recurrence of stenosis after angioplasty. Thus, routine surveillance for graft stenosis, with preemptive angioplasty, cannot be recommended for reduction of graft thrombosis. Future research should be directed at pharmacologic interventions to prevent graft stenosis.
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Affiliation(s)
- Michael Allon
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA.
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CHAN MR, YOUNG HN, YEVZLIN AS. The effect of in-stent restenosis on hemodialysis access patency. Hemodial Int 2009; 13:250-6. [DOI: 10.1111/j.1542-4758.2009.00389.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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