Feasibility of trans-radial approach in percutaneous intervention for upper arm dialysis access

Endovascular Treatment of Malfunctioning Dialysis Fistulas: A Multicenter Retrospective Analysis Comparing Transradial and Conventional Transvenous Access

BACKGROUND

Venous outflow is the favored access for endovascular management of dialysis fistulas. However, transradial access (TRA) offers advantages in specific clinical scenarios. The study aims to compare the efficacy, feasibility, and safety of TRA and transvenous access (TVA) in the endovascular management of malfunctioning dialysis fistulas, addressing the existing gap in comprehensive literature.

METHODS

A retrospective multi-center analysis included prospectively collected data (January 2021-November 2023) from patients undergoing endovascular management of malfunctioning dialysis fistulas with TRA. Control groups comprised patients with TVA.

RESULTS

Of 206 patients, 62 underwent TRA, and 144 underwent TVA. Baseline demographics showed a well-matched distribution. TRA exhibited longer cannulation times but similar procedural and fluoroscopy times. Technical success rates were high for both TRA (98.4%) and TVA (97.2%). Clinical success rates were comparable (96.8% vs. 95.8%). Postprocedure access flow rates and complications demonstrated no significant differences.

CONCLUSIONS

This study provides the first direct comparison of TRA and TVA in malfunctioning dialytic fistulas. While venous outflow remains the standard vascular access site for managing malfunctioning dialysis fistulas, TRA shows comparable efficacy, safety, and feasibility, making it a viable alternative in specific clinical contexts. Further studies are needed to confirm these findings and to determine the long-term durability of TRA.

The trans-radial approach for endovascular intervention of the problem arterio-venous fistula: A single-centre case series and systematic review

INTRODUCTION

The arteriovenous fistula (AVF) is the gold standard access modality for haemodialysis, but due to patient and technical factors, it is prone to stenosis and thrombosis. The trans-radial approach offers multiple unique benefits, but its safety, efficiency and efficacy have not been rigorously studied in the context of the AVF. This study provides a case series of trans-radial AVF procedures, and a systematic review and meta-analysis of existing literature to solidify the role of the trans-radial approach in endovascular AVF surgery.

METHODS

Surgical records were interrogated to identify all trans-radial AVF interventions between 2019 and 2021. The primary endpoints were procedure time and complication rates. The secondary endpoints were primary assisted patency and increase in pre- and post-operative brachial artery blood flow. The systematic review was performed by searching MEDLINE, Embase and CENTRAL from 2000 to 2023.

RESULTS

The case series identified 76 consecutive procedures performed on 49 patients. Mean procedure time was 64 min, and only one complication, a puncture site haematoma, was identified. Mean postoperative AVF flow increase was 342 mL/min (p < 0.001). Primary-assisted patency at 6 and 12 months was 91% and 82% respectively. The systematic review included 16 studies totalling 1163 procedures with a mean MINORS score of 69%. Mean procedure time was 44 min. Complications were rare: procedural failure (1.2%), haematoma (0.90%), radial artery occlusion (0.74%) and pseudoaneurysm (0.12%). Post-procedural flow increased by an average of 274 mL/min. Pooled primary-assisted patency rates at 6 and 12 months were 88% and 77% respectively.

CONCLUSION

The trans-radial approach allows for expedient, safe and durable AVF endovascular surgery, however this technique would benefit from prospective evaluation.

Snuffbox distal transradial access (dTRA) for arteriovenous fistuloplasty in Singapore: Going distal is safe

AIM

Arteriovenous fistula (AVF) dysfunction resulting from stenosis or occlusion, is a prevalent issue in end-stage renal failure patients reliant on autogenous AVFs for dialysis. Recently, a distal transradial approach (dTRA) has emerged, offering advantages such as diminished access site complications, better patient comfort and reduced risk of radial artery occlusion. Our study seeks to assess the effectiveness, outcomes and complication rates of employing dTRA for arteriovenous fistuloplasty in Singaporean patients.

METHODS

A retrospective review of all dTRA fistuloplasties performed on dysfunctional or slow to mature AVFs from 2017 to 2023 in our institution was performed. Patients with a distal radial artery measuring 2 mm or more with no evidence of occlusion or thrombosis were included. Patients who required central venoplasty or cutting balloon angioplasty were excluded. Outcome measures included technical success, mean procedure duration, complications and post-intervention primary patency at 1, 3 and 6 months. Patients were followed up for 12 months post-intervention.

RESULTS

A total of 37 patients were included. 97.3% of patients undergoing dTRA fistuloplasty had radiocephalic fistulas while 2.7% had brachiobasilic fistulas. There was 100% technical success (defined as success in radial artery cannulation, sheath insertion and crossing of stenotic lesions) in our study as all patients successfully underwent fistuloplasty via dTRA approach. One-month patency rate was 97.4%, 3-month patency rate was 92.1% and 6-month patency rate was 86.8%. There were no immediate complications (haematoma, infection, bleeding, pseudoaneurysm, occlusion) of the radial artery post-intervention.

CONCLUSION

Our paper illustrates the safety and efficacy of utilising dTRA for arteriovenous fistuloplasty. This approach offers distinct benefits in addressing non-mature or dysfunctional distal forearm arteriovenous fistulas and should be taken into account in anatomically suitable cases.

Transradial access for arteriovenous fistuloplasty in Singapore

BACKGROUND

Endovascular balloon angioplasty is standard therapy for dysfunctional arteriovenous fistula in end-stage renal failure patients on hemodialysis. Venous antegrade or retrograde puncture of the fistula is typically performed to gain access for fistuloplasty. Transradial approach for brachiocephalic or brachiobasilic arteriovenous fistulas offers an alternative method of access with the advantage of addressing multi-focal juxta-anastomotic and venous stenosis from the same approach. We aim to review the efficacy, outcomes and complication rates of transradial access for arteriovenous fistuloplasty among patients in Singapore.

METHODS

A retrospective review of 195 endovascular fistuloplasties from September 2017 to August 2019, at a tertiary university hospital Vascular Surgery unit.

RESULTS

Of 195 fistuloplasties, 43 (22%) were transradial approach (23 brachiocephalic arteriovenous fistulas, 20 brachiobasilic arteriovenous fistulas) in 33 patients (67% male and mean age = 65 years). Of these 43 procedures, 11 (26%) were performed as balloon-assisted maturation fistuloplasties while 32 (74%) were performed for mature arteriovenous fistulas with multi-focal juxta-anastomosis and venous stenosis. Technical success rate was 95% with mean procedure duration at 43.5 ± 14.6 min. Mean pre- and post-fistuloplasty dialysis access flow rates increased from 502 to 952 ml/min (p < 0.001). Post-intervention primary patency was 100%, 66% and 20% at 1, 6 and 12 months, respectively. There were four patients with non-limb-threatening radial artery thrombosis (9.3%) while there was no radial artery pseudoaneurysm or post-procedural bleeding.

CONCLUSION

Transradial approach for arteriovenous fistuloplasty is a safe and feasible option in patients requiring balloon-assisted maturation or with multi-focal juxta-anastomotic and venous stenosis.

Radial artery approach to salvage nonmaturing radiocephalic arteriovenous fistulas

PURPOSE

To evaluate the usefulness of an approach through the radial artery distal to the arteriovenous anastomosis for salvaging nonmaturing radiocephalic arteriovenous fistulas.

METHODS

Procedures that fulfilled the following criteria were retrospectively reviewed: (1) autogenous radiocephalic fistulas, (2) fistulas less than 3 months old, (3) distal radial artery approach for salvage. From 2005 to 2011, a total of 51 patients fulfilling the above criteria were enrolled. Outcome variables were obtained from angiographic, clinical and hemodialysis records, including the success, complication, and primary and secondary patency rates.

RESULTS

The overall anatomical and clinical success rates for the distal radial artery approach were 96 and 94%, respectively. The average procedure time was 36 ± 19 min. Six patients (12%) experienced minor complications as a result of extravasations. No arterial complication or puncture site complication was noted. The postinterventional 6-month primary patency rate was 51%, and the 6-month secondary patency rate was 90%. When the patients were divided into a stenosed group (20 patients) and an occluded group (31 patients), there were no differences in the success rate, complication rate, or primary and secondary patency rates.

CONCLUSION

An approach through the radial artery distal to the arteriovenous anastomosis is an effective and safe alternative for the salvage of nonmaturing radiocephalic arteriovenous fistulas, even for occluded fistulas.