Primary Cutting Balloon Angioplasty for Treatment of Venous Stenoses in Native Hemodialysis Fistulas: Long-Term Results from Three Centers

Aim To evaluate the technical success and patency rates following primary cutting balloon angioplasty for venous stenoses in native dialysis fistulas. Methods Forty-one patients (26 men, 15 women; age range 26–82 years, average age 59 years) underwent 50 (repeat procedures in 9 patients) primary cutting balloon (PCB) angioplasty procedures in three institutions by three primary operators. The indication was primary stenosis in 21 patients, recurrent lesions in 15, and immature fistulas in 5. A PCB was used alone in 17 cases, but was followed by a larger standard balloon in 33 cases. Follow-up included ultrasound, flow analysis and urea reduction ratio, and ranged from 2 to 30 months (mean 14 months). Results The technical success rate was 98%. All procedures were relatively painless. Two PCBs burst and 4 leaked, but without causing any morbidity. Nineteen fistulas were still working at last follow-up. Primary patency rates at 6, 12, and 24 months using Kaplan-Meier analysis were 88%, 73%, and 34%, respectively, and the primary assisted patencies were 90%, 75%, and 50%, respectively. Conclusion PCB angioplasty has high technical success and low complication rates. The long-term patency rates are favorable for PCB angioplasty and compare favorably with other series.     

Randomized Clinical Trial of Cutting Balloon Angioplasty versus High-Pressure Balloon Angioplasty in Hemodialysis Arteriovenous Fistula Stenoses Resistant to Conventional Balloon Angioplasty

PurposeTo compare the efficacy and safety of cutting balloon angioplasty (CBA) versus high-pressure balloon angioplasty (HPBA) for the treatment of hemodialysis autogenous fistula stenoses resistant to conventional percutaneous transluminal angioplasty (PTA).Materials and MethodsIn a prospective, randomized clinical trial involving patients with dysfunctional, stenotic hemodialysis arteriovenous fistulas (AVFs), patients were randomized to receive CBA or HPBA if conventional PTA had suboptimal results (ie, residual stenosis > 30%). A total of 516 patients consented to participate in the study from October 2008 to September 2011, 85% of whom (n = 439) had technically successful conventional PTA. The remaining 71 patients (mean age, 60 y; 49 men) with suboptimal PTA results were eventually randomized: 36 to the CBA arm and 35 to the HPBA arm. Primary and secondary target lesion patencies were determined by Kaplan–Meier analysis.ResultsClinical success rates were 100% in both arms. Primary target lesion patency rates at 6 months were 66.4% and 39.9% for CBA and HPBA, respectively (P = .01). Secondary target lesion patency rates at 6 months were 96.5% for CBA and 80.0% for HPBA (P = .03). There was a single major complication of venous perforation following CBA. The 30-day mortality rate was 1.4%, with one non–procedure-related death in the HPBA group.ConclusionsPrimary and secondary target lesion patency rates of CBA were statistically superior to those of HPBA following suboptimal conventional PTA. For AVF stenoses resistant to conventional PTA, CBA may be a better second-line treatment given its superior patency rates.     

Cutting balloon angioplasty for primary treatment of hemodialysis fistula venous stenoses: preliminary results

PURPOSE: To assess the efficacy of the cutting balloon as the primary tool in percutaneous transluminal angioplasty of hemodialysis access stenoses. MATERIALS AND METHODS: A prospective study of symptomatic patients with stenoses of 50% or more in their hemodialysis accesses was undertaken. Provided that no contraindication to the use of cutting balloons existed, the stenoses were treated with the cutting balloon with use of a maximum of a 1:1.1 ratio between expected vessel diameter and balloon diameter. In cases in which dilation to the full diameter of the cutting balloon left a greater than 30% residual stenosis, postprocedural dilation with conventional balloons was carried out. Patient access function was followed. Twenty-nine patients with 42 stenoses have now reached 6 months of follow-up after cutting balloon angioplasty. RESULTS: Technical and clinical success rates were 100%. Slight local extravasation occurred in three cases: two had continued pain after the balloon was deflated and were therefore treated with balloon compression with resolution of symptoms and angiographic findings. In two cases, elastic recoil required stent placement to correct the stenosis. At 6 months, 22 patients (76%) remain in the primary patency category. Inclusion of those with primary assisted patency yields 26 patients (90%), and an additional patient had secondary patency, for a total of 93%. Two patients died of causes not directly related to dialysis. CONCLUSION: The high degree of technical and clinical success likely reflects the lack of major complications. The 6-month follow-up results match those of other series. Further follow-up will show whether this technique produces better results over the long term.     

Cutting balloon angioplasty for resistant venous stenoses of Brescia-Cimino fistulas

Peripheral cutting balloons with diameters of 5-8 mm were employed to dilate eight resistant stenoses among 62 venous stenoses in 48 Brescia-Cimino fistulas. The grade of stenosis after high-pressure balloon angioplasty ranged from 57% to 87% (median, 75%). The residual stenosis after cutting balloon angioplasty ranged from 0 to 24% (median, 10.5%). Two complications occurred among these eight cases, one of which was treated by stent placement. No repeated intervention was necessary during follow-up (range, 74-249 days; median, 141 days). Cutting balloon angioplasty was effective to overcome the resistance of venous stenosis in hemodialysis fistulas.     

Salvage of nonmaturing native fistulas by using angioplasty

PURPOSE: To retrospectively review outcomes following angioplasty of nonmaturing autogenous hemodialysis fistulas. MATERIALS AND METHODS: Institutional review board exemption was received for this HIPAA-compliant retrospective study; informed consent was waived. During 48 months, 101 patients underwent fistulography for percutaneous salvage of nonmaturing native fistulas. Clinical and technical success, need for secondary interventions, and complications were recorded according to consensus definitions. Patency following angioplasty was estimated with the Kaplan-Meier technique. Patient age, sex, ethnicity, fistula age, fistula type, number of stenoses, maximal angioplastic balloon diameter used, and presence of palpable thrill following angioplasty were examined as predictors of primary patency of the fistula following intervention by using Cox proportional hazards model. RESULTS: Mean patient age was 58 years; 35% were women. Median time from fistula creation to fistulography was 2.5 months. Hemodynamically significant (>50%) stenoses were identified in 88% (89 of 101) of patients; angioplasty was attempted in 96% (85 of 89). Technical success was achieved in 92% (78 of 85) of fistulas following angioplasty; clinical success of normal hemodialysis with total access blood flow of more than 500 mL/min occurred following 88% (75 of 85) of angioplastic interventions. No major and two minor complications occurred. Mean primary unassisted patency at 3, 6, and 12 months was 60%+/-6% (95% confidence interval), 45%+/-6%, and 34%+/-6%, respectively. Additional angioplasty (n=12), stent placement (n=1), or thrombectomy (n=1) during subsequent interventions resulted in mean secondary patency at 3, 6, and 12 months of 82%+/-4%, 79%+/-5%, and 75%+/-6%, respectively. Patients without thrill following angioplasty were more than twice as likely to lose patency as patients with thrill (P=.035). No relationship was seen between primary patency and other predictors examined. CONCLUSION: Early fistulography enables identification of underlying areas of stenosis in nonmaturing fistulas, which can be safely and effectively treated with angioplasty. With continued surveillance and repeat interventions, functional patency can be sustained in the majority of fistulas.     

Use of the peripheral cutting balloon to treat hemodialysis-related stenoses

PURPOSE: To compare the effectiveness and safety of use of the peripheral cutting balloon (PCB) versus standard percutaneous transluminal angioplasty (PTA) for the treatment of hemodialysis-related stenoses. MATERIALS AND METHODS: This prospective, randomized multicenter clinical trial included 340 patients with stenotic or thrombosed hemodialysis grafts who were randomized to receive treatment with the PCB or PTA for venous outflow stenosis. One hundred seventy-three patients underwent treatment with the PCB, 101 with stenotic grafts and 72 with thrombosed grafts. PTA was used to treat 167 patients, 94 patients with stenotic grafts and 73 with thrombosed grafts. The follow-up period extended for 6 months. RESULTS: The procedural success rates were 80.8% and 75.4% for the PCB and PTA groups, respectively (P = .24). With use of the PCB, the primary patency rates of the target lesions were 84.3%, 65.8%, and 47.9% at 1 month, 3 months, and 6 months, respectively. With PTA, the primary patency rates of the target lesions were 77.7%, 63.4%, and 40.5% at 1 month, 3 months, and 6 months, respectively. The primary patency rates of the entire vascular access circuit were 82.6%, 61.0%, and 43.3% at 1 month, 3 months, and 6 months, respectively, with use of the PCB. For patients who were treated with PTA, the primary patency rates of the vascular access circuit were 75.9%, 61.0%, and 36.3% at 1 month, 3 months, and 6 months, respectively. When comparing the PCB and PTA, there was no difference in the 6-month primary patency rates in the target lesion (P = .373) or the entire vascular access circuit (P = .531). There were nine device-related complications in the PCB group (5.2%): five venous ruptures (2.9%), three venous dissections (1.7%), and one case of thrombosis (0.6%). There were no device-related complications in the PTA group. CONCLUSION: This prospective, randomized trial comparing use of the PCB versus standard PTA for treatment of hemodialysis-related venous stenoses demonstrated that the PCB provides equivalent 6-month patency to PTA for stenotic and thrombosed grafts.     

Insufficient hemodialysis access fistulas: late results of treatment with percutaneous balloon angioplasty

Forty-six patients with malfunctioning hemodialysis access fistulas were treated with balloon angioplasty. The initial percutaneous transluminal angioplasty procedure was successful in 16 (89%) of 18 patients with stenoses and in 13 (46%) of 28 with occlusions. In ten patients (seven with stenoses and three with occlusions) repeated dilation (two to five times; mean, two times) became necessary due to recurrent malfunction 1-24 months (mean, 6 months) after the first intervention. In the 16 patients with stenoses, the patency rate after 6 months was 93%; after 1 year, 91%; and after 2 years, 57%. In the 12 patients with occlusions, the rates were 80%, 50%, and 14%, respectively. Dilation of stenoses in malfunctioning hemodialysis fistulas is the procedure of choice. If hemodialysis shunts malfunction, immediate dilation of stenotic lesions should be performed to prevent occlusion.     

Usefulness of paclitaxel-releasing high-pressure balloon associated with cutting balloon angioplasty for treatment of outflow stenoses of failing hemodialysis arteriovenous shunts

Aim

To evaluate the technical and clinical success, primary patency (PP) and complications of angioplasty performed with paclitaxel-coated balloon (PCBs) associated with cutting balloon and for the treatment of the outflow stenoses of failing hemodialysis arteriovenous shunt.

Material and methods

From September 2014 to September 2015, 50 patients with 66 stenoses were registered. Vascular accesses were autogenous (n = 20) and prosthetic (n = 30). Stenosis were documented during follow-up with routine echo-color Doppler, clinical evaluation and in the remaining incidentally during fistulography. Angioplasty was performed with cutting balloon and afterward with PCB. The mean follow-up time was 8 months (range 6–15 months). Technical success, clinical success, primary patency and complications were registered.

Results

Technical success was 100 %. Clinical success was 94.7 %. Primary patency rate was 87.7 %; in five patients, a significant re-stenosis (≥50 %) was registered. A residual asymptomatic stenosis (<30 %) was registered in four cases (7 %). No major complications were registered.

Conclusions

A short-term patency benefit may be obtained including PCB in angioplasty treatment of failing hemodialysis arteriovenous shunts.

     

The primary patency of drug-eluting balloon versus conventional balloon angioplasty in hemodialysis patients with arteriovenous fistula stenoses

Objective

The aim of this article is to assess and compare the rate of primary patency achieved by drug-eluting balloon angioplasty (DEBA) and conventional balloon angioplasty (CBA) in hemodialysis arteriovenous fistula stenoses.

Methods

This retrospective study consists of 52 patients with significant arteriovenous fistulas stenoses who were treated with DEBA (n = 26) or CBA (n = 26) between January 2013 and January 2015. Only those patients with postprocedural technical and clinical success of 100 % were selected from the database. Primary patency rates of fistulas at 6 and 12 months were evaluated with Doppler ultrasonography as well as clinically. The Kaplan-Meier method was used to compare the primary assisted patency rates for the two groups.

Results

The type of AVFs were 41 (78.8 %) radiocephalic and 11 (21.2 %) brachiocephalic. Primary patency rates between the DEBA and CBA group had a statistically significant difference at 12 months (p < 0.05). However there was no statistically significant difference at the 6-month follow-up period (p = 0.449). There was no statistically significant difference among the patient age, patient gender and fistula type of the two groups (p > 0.05).

Conclusion

Drug-eluting balloon angioplasty proved to be an effective treatment of hemodialysis AVFs stenosis, with a high primary patency rate at 12 months.

     

Primary patency with cutting and conventional balloon angioplasty for different types of hemodialysis access stenosis

PURPOSE: To compare primary patency rates of cutting balloon percutaneous transluminal angioplasty (PTA) (hereafter, cutting PTA) and conventional balloon PTA (hereafter, conventional PTA) in the treatment of different types of hemodialysis access stenosis. MATERIALS AND METHODS: The institutional review board approved this study. Written informed consent was obtained for the prospective component of this study and waived for the retrospective component. Patients in whom treatment with cutting PTA alone or conventional PTA alone was clinically successful formed the two study groups. Primary patency for the lesion was defined as uninterrupted patency of the treated site after balloon PTA. A site was no longer considered patent when the patient underwent treatment for hemodialysis access failure due to restenosis of the treated site. Primary patency rates for lesions were calculated with the Kaplan-Meier method according to the type of stenosis. We compared the two groups by using the log-rank test to determine statistical significance. RESULTS: In the cutting PTA group, 62 patients with 77 stenoses (32 men, 30 women; mean age, 65.5 years +/- 10.1 [standard deviation]) achieved clinical success. In the conventional PTA group, 52 patients with 68 stenoses (23 men, 29 women; mean age, 61.9 years +/- 10.2) achieved clinical success. In patients with autogenous venous stenosis, no significant difference in the primary patency rate was noted between groups (P = .369). In patients with graft-to-vein anastomotic stenosis, the primary patency rate was significantly higher for cutting PTA than for conventional PTA (P = .39). In patients with intragraft stenosis, no significant difference in the primary patency rate was noted between groups (P = .379). In patients with in-stent restenosis, no significant difference in the primary patency rate was noted between groups (P = .923). CONCLUSION: Primary patency rates are significantly higher for cutting PTA in the treatment of graft-to-vein anastomotic stenosis; however, no significant differences in primary patency rates exist between these PTAs in the treatment of autogenous venous stenosis, intragraft stenosis, or in-stent restenosis.     

Pharmacomechanical thrombectomy with the Castañeda brush catheter in thrombosed hemodialysis grafts and native fistulas

PURPOSE: To evaluate the safety and efficacy of the Casta?eda brush catheter in the treatment of thrombosed hemodialysis fistulas and grafts. MATERIALS AND METHODS: Twenty-six revascularization procedures with the Casta?eda brush catheter combined with urokinase were retrospectively analyzed in 21 patients (mean age, 69 years; range, 35-87 y). Hemodialysis shunts were native arteriovenous (AV) fistulas (n=15; 16 procedures) or polytetrafluoroethylene grafts (n=6; 10 procedures). Major outcomes included procedure time, anatomic and clinical success rates, complication rate, and primary, primary assisted, and secondary patency. RESULTS: In 26 procedures, the brush catheter was used in combination with a mean dose of 239,792 IU urokinase (range, 60,000-300,000 IU). Additional angioplasty was performed in all procedures; five procedures (19%) required additional stent implantation. Mean procedure time was 99.2 minutes (range, 49-261 min). Anatomic and clinical success rates were 100% and 96.2%, respectively. Two minor complications (8%) occurred, neither of which was device-related: one case of extravasation treated by balloon tamponade and one hematoma at the distal puncture site without the need for surgery or transfusion. Primary patency rates were 87%, 62%, and 50% at 3, 6, and 12 months, respectively, for AV fistulas, and 50%, 33%, and 17%, respectively, for grafts. Assisted primary patency rates were 93%, 77%, and 70% at 3, 6, and 12 months, respectively, for AV fistulas, and 50%, 33%, and 17%, respectively, for grafts. At 3, 6, and 12 months, secondary patency rates were 93%, 85%, and 80%, respectively, for AV fistulas, and 83%, 67%, and 50%, respectively, for grafts. CONCLUSIONS: The Casta?eda brush catheter is a safe and effective pharmacomechanical thrombectomy device for the treatment of thrombosed hemodialysis grafts and native fistulas.     

Cutting balloon percutaneous transluminal angioplasty for salvage of lower limb arterial bypass grafts: feasibility

PURPOSE: To evaluate the feasibility of cutting balloon percutaneous transluminal angioplasty (PTA) for treatment of neointimal hyperplasia in peripheral arterial bypass grafts. MATERIALS AND METHODS: Fifteen consecutive patients (six women, nine men; age range, 57-89 years; mean age, 71 years) were treated with cutting balloon PTA for 16 anastomotic stenoses after infrainguinal bypass (prosthetic grafts, seven patients; prosthetic-vein composite grafts, two; venous grafts, five; and ileofemoral stent-graft, one). Cutting balloon PTA was followed by conventional PTA to improve anastomotic diameter. Patients with stenotic vein grafts underwent cutting balloon PTA after failed conventional PTA; the other patients were treated primarily with cutting balloon PTA. Criteria for success were a lumen diameter improvement of greater than 50% or residual stenosis of 20% or less. Follow-up was performed with color duplex ultrasonographic surveillance. Patency rates and durations were calculated with Kaplan-Meier survival curves and log-rank statistics. RESULTS: Attempted conventional PTA (n = 6) prior to cutting balloon PTA was unsuccessful. Cutting balloon PTA was technically successful in 15 (94%) of 16 lesions, without clinical complications. Two local restenoses and one graft occlusion occurred between 5 and 7 months. The cumulative 6-month primary and secondary graft patency rates were 84% and 92%, respectively. At 12 and 18 months, they were 67% (95% CI: 0.34, 0.86) and 83% (95% CI: 0.48, 0.96), respectively; mean follow-up was 10.0 months. CONCLUSION: Cutting balloon PTA proved feasible for treatment of resistant peripheral arterial bypass graft stenosis, commonly caused by neointimal hyperplasia, with excellent technical success. Short-term patency with this technique appears to be superior to that with conventional PTA, and it compares well with patency of atherectomy for salvage of infrainguinal bypass grafts.     

Mechanical Thrombectomy of Occluded Hemodialysis Native Fistulas and Grafts Using a Hydrodynamic Thrombectomy Catheter: Preliminary Experience

The purpose of this study was to evaluate the efficacy and safety of a new hydrodynamic percutaneous thrombectomy catheter in the treatment of thrombosed hemodialysis fistulas and grafts. Twenty-two patients (median age: 47 years; range: 31–79 years) underwent mechanical thrombectomy for thrombosed hemodialysis fistulas or polytetrafluoroethylene (PTFE) grafts. In all cases, an Oasis hydrodynamic catheter was used. Five patients had native fistulas and 17 had PTFE grafts. Six patients required repeat procedures. All patients with native fistulas and 15 of the 17 with PTFE grafts also underwent angioplasty of the venous limb following the thrombectomy. Major outcome measures included technical success, clinical success, primary and secondary patency, and complication rates. Twenty-eight procedures were performed in total. The technical success rate was 100% and 90% and clinical success was 86% and 76% for native fistulas and grafts, respectively. The primary patency at 6 months was 50% and 59% for fistulas and grafts, respectively, and the secondary patency at 6 months was 75% and 70% for fistulas and grafts, respectively. Two patients died of unrelated causes during the follow-up period. The Oasis catheter is an effective mechanical device for the percutaneous treatment of thrombosed hemodialysis access. Our initial success rate showed that the technique is safe in the treatment of both native fistulas and grafts.     

Angioplasty of Long Venous Stenoses in Hemodialysis Access: At Last an Indication for Cutting Balloon?

PURPOSE: To compare the postintervention primary patency rates of cutting balloon angioplasty (CBA) with those of conventional percutaneous transluminal angioplasty (PTA) in the treatment of hemodialysis-related stenoses at least 2 cm long. MATERIALS AND METHODS: This retrospective and controlled study included 29 patients with a hemodialysis-related stenosis at least 2 cm long. From August 2002 to August 2003, nine patients (PTA group, six upper-arm and three forearm fistulas) were treated with a conventional balloon (5-8 mm, 4 cm long). From September 2003 to December 2005, 20 patients (CBA group, 12 upper-arm and seven forearm fistulas; one polytetrafluoroethylene hemodialysis graft) were treated with a cutting balloon (5-7 mm, 1 cm long). The median follow-up was 22.1 months for the CBA group and 15.6 months for the PTA group. The Kaplan-Meier method was used to calculate the primary cumulative patency rates, and the log-rank test was used for comparison. Multivariate Cox models were generated by combining three variables: patient age, stenosis length, and treatment type (CBA or PTA). RESULTS: In the CBA group, the postintervention primary patency was 85% +/- 16 at 6 months, 70% +/- 20 at 1 year, and 32% +/- 26 at 18 months. In the PTA group, the postintervention primary patency was 56% +/- 32 at 6 months and 21% (range, 0%-53%) at 1 year. When comparing PTA versus CBA with the log-rank test, there was a statistically significant difference (P = .009). With the multivariate Cox models, treatment was again a statistically significant (P = .007) determinant of primary patency; patient age and stenosis length were not. CONCLUSION: The use of a cutting balloon as the first-line treatment for stenoses at least 2 cm long significantly improves the postintervention primary patency rate.     

Early rethrombosis of clotted hemodialysis grafts: graft salvage achieved with an aggressive approach

OBJECTIVE: The purpose of this study was to assess the efficacy of repeated pulsed spray pharmacomechanical thrombolysis for salvage of early rethrombosis of hemodialysis grafts and to identify factors that predict successful outcome. MATERIALS AND METHODS: Thirty-four patients with initial successful thrombolysis were referred for repeated thrombolysis because of early rethrombosis. Repeated thrombolysis occurred within 1 month of initial thrombolysis. Technical success and patency rates were calculated. Causes of graft thrombosis and procedural modifications were analyzed. RESULTS: The 39 rethrombosed grafts were successfully treated using pharmacomechanical thrombolysis, and patients underwent subsequent hemodialysis. The underlying flow-limiting stenoses were treated with balloon angioplasty using a larger balloon (41%), a same-size angioplasty balloon (18%), stent placement (15%), or increased anticoagulation (5%). A new stenosis location was discovered in 18%. Mean primary patency was 80.9 days (2.6 months) and secondary patency was 235.4 days (7.8 months). With life table analysis, 1-, 3-, 6-, and 12-month primary patency rates were 72%, 31%, 23%, and 15%, and secondary patency rates were 77%, 62%, 51%, and 31%, respectively. Graft patency rates in our study were compared with our institutional historic graft patency rates, with no significant difference noted (p = 0.76). No major procedural complications occurred. CONCLUSION: Adequate technical success and patency rates for pharmacomechanical thrombolysis occur even for hemodialysis grafts that rethrombose within 1 month. After thrombolysis, aggressive search for and treatment of additional stenoses are warranted.     

Cutting Balloon Angioplasty Versus Standard Balloon Angioplasty for Failing Infra-inguinal Vein Grafts: Comparative Study of Short- and Mid-Term Primary Patency Rates

Purpose To evaluate the results of a recent change in practice in our institution using cutting balloon angioplasty instead of standard balloon angioplasty as the primary treatment for failing infra-inguinal vein bypass grafts. Methods In this nonrandomized cohort study with a historical control, failing infra-inguinal vein grafts were identified at duplex surveillance or clinical examination. Patients had confirmatory arteriography and balloon angioplasty at the same attendance. Interventions proximal or distal to the graft itself and prosthetic grafts were not included. Patients were entered into a duplex graft surveillance program. Initial assessment of technical success was duplex or improvement 4–6 weeks after the primary angioplasty. Results Twenty-seven consecutive patients were treated with standard balloon angioplasty, then 11 consecutive patients were treated with cutting balloon angioplasty. Initial technical success was 74% for the standard balloon versus 82% for the cutting balloon. The primary patency rate at 6 months was 16/26 (62%) for standard balloon angioplasty and 8/10 (80%) for cutting balloon angioplasty (p = 0.44). The primary patency rate at 12 months was 9/25 (36%) for standard balloon angioplasty and 5/10 (50%) for cutting balloon angioplasty (p = 0.47). Conclusion The use of cutting balloons for primary angioplasty of infra-inguinal vein grafts offers no definite advantage over standard balloon angioplasty in this institution or compared with patency rates after standard balloon angioplasty reported elsewhere. Larger multicenter studies would be required to demonstrate whether there was any real difference between the two techniques.     

Percutaneous transluminal cutting-balloon angioplasty for hemodialysis access stenoses resistant to conventional balloon angioplasty

Purpose: To examine the value of cutting-balloon percutaneous transluminal angioplasty (PTA) for hemodialysis access with residual stenosis after conventional balloon PTA.

Material and Methods: Angioplasty with conventional balloons was performed on 48 hemodialysis access stenoses in 28 patients. If the balloon waist still remained at the rated burst pressure, the balloon was reinflated up to three times. Fifteen of 48 stenoses had residual stenoses of more than 30% after conventional balloon PTA. In these 15 stenoses, additional cutting-balloon PTA was performed.

Results: The mean residual percent diameter stenoses before and after conventional balloon PTA were 77.6±3.4% and 48.6±8.5%, respectively. Additional cutting-balloon PTA decreased the mean residual percent diameter to 27.9±10.0%, and the cutting balloon was completely inflated without complication. In 12 patients, the 6-month primary patency rate (±SE) was 90.0% (9.5), and the 1-year primary patency rate (±SE) was 25.0% (14.8).

Conclusion: Additional cutting-balloon PTA was found useful for reducing residual stenosis.     

Use of expanded polytetrafluoroethylene-covered nitinol stents for the salvage of dysfunctional autogenous hemodialysis fistulas

The use of expanded polytetrafluoroethylene (ePTFE)-covered nitinol stents for salvage of hemodialysis fistulas was retrospectively examined. Seven covered stents were placed in five patients with failing fistulas considered unsalvageable. Indications included recurrent stenoses, thrombosis, and pseudoaneurysm formation. Before intervention, all patients required multiple interventions. The technical success rate was 100%. The primary patency rate was 80%, with secondary patency and lesion patency rates of 100% at 9 months. The incidence of follow-up repeat intervention was 0.3 per year. There were no complications. The use of ePTFE-covered stent placement in dysfunctional autogenous fistulas is technically feasible and, in this small series, was effective in preserving function and preventing access abandonment.     

Percutaneous transluminal angioplasty of malfunctioning Brescia-Cimino arteriovenous fistula: analysis of factors adversely affecting long-term patency

Our objective was to identify the factors adversely affecting long-term patency after percutaneous transluminal angioplasty (PTA) for hemodialysis Brescia-Cimino arteriovenous fistulas. Between November 1995 and March 2000, 91 PTA procedures were performed on 50 patients with 57 Brescia-Cimino fistulas. A retrospective study based on the chart review was performed. The initial technical success rate for all procedures and the primary and secondary patency rates for all fistulas were calculated. Regarding fistulas successfully maintained by the primary PTA, the primary and secondary patency rates were compared using the Kaplan-Meier method between two patient groups. They were classified on the basis of several factors, including age (older, over 70 years, and younger group), age of the fistulas (older, over 6 months, and younger group), with or without diabetes mellitus (DM), solitary or multiple lesions, long or short segment lesion, stenosis or occlusion, and with or without arterial and/or anastomotic lesions. Initial technical success rates for all procedures and fistulas were 91.2 and 89.5%, respectively. Cumulative primary and secondary patency rates at 1 year were 47.3 and 67.3%, respectively. In the comparative study, the secondary patency rate for the older group was lower than that of the younger group with statistical significance ( p =0.029). The higher age is the only factor that reduces the long-term patency rate after PTA.     

Prospective study of balloon inflation pressures and other technical aspects of hemodialysis access angioplasty

PURPOSE: Balloon angioplasty is a mainstay in the treatment of failing or thrombosed hemodialysis access grafts and fistulas. A sizable body of outcomes data exists concerning percutaneous transluminal angioplasty (PTA) in hemodialysis access, yet there is a relative paucity of technical information available, especially regarding dilation pressures. The aim of the present study was to compile such information, which can be critical to the choice of devices for PTA and to the design of future clinical trials seeking to improve outcomes in this area. MATERIALS AND METHODS: Technical data were collected prospectively for 102 PTA procedures (66 prophylactic PTA procedures and 36 PTA procedures performed during access thrombectomy). Demographic data concerning the access were collected. Technical data were collected individually for each lesion treated, including lesion location; degree of stenosis (in quartiles); lesion length; PTA balloon brand, size, and length; pressure at which the waist of the balloon was effaced; residual stenosis; and reason for additional balloons or inflations if used. Outcomes data other than residual stenosis were not collected, but the endpoint for all interventions was a thrill in the access. RESULTS: A total of 230 lesions were treated. Two (1%) could not be successfully treated with PTA despite the use of "ultra high" pressure (approximately 40 atm); one was treated successfully with parallel wire technique and the other was revised surgically after the use of a cutting balloon also failed. Overall, 55% of lesions required pressures greater than 15 atm to efface the waist. Excluding initial failures, 20% of lesions in native fistulas and 9% in grafts required very high pressure (>20 atm) to efface the waist (P = .02). High pressure was needed less frequently in PTA procedures performed in the setting of thrombectomy procedures than in prophylactic PTA procedures (P = .0001). Residual stenosis was positively correlated with severity of initial stenosis and negatively correlated with duration of inflation. CONCLUSIONS: Conventional angioplasty balloons are inadequate for the treatment of most hemodialysis access stenoses. High pressures (>15 atm) are commonly needed for PTA in hemodialysis access. Very high pressures (>20 atm) are more frequently needed in native fistulas.