Long-Term Results from the Pivotal Multicenter Trial of Ultrasound-Guided Percutaneous Arteriovenous Fistula Creation for Hemodialysis Access

PurposeTo report the 5-year results from the Pivotal Multicenter Trial of Ultrasound-Guided Percutaneous Arteriovenous Fistula (pAVF) Creation for Hemodialysis Access.Materials and MethodsThe retrospective review of 107 intent-to-treat (ITT) patients from the pivotal trial provided a long-term follow-up population (LTP) of 85 patients with a median follow-up duration of 50 months (range, 12–60 months). Data evaluated in the LTP group were fistula maturation and usage, secondary procedures, and complications. The Kaplan-Meier analysis of primary patency, assisted primary patency, cumulative patency, and functional patency (time from 2-needle cannulation to abandonment) were performed for the ITT population.ResultsIn the LTP, 99% (84 of 85) of fistulae were mature, with 99% (78 of 79) of patients requiring hemodialysis using their pAVF. Sustained fistula use (2-needle cannulation at the prescribed rate, 2 of 3 sessions) was achieved in 92% (78 of 85) of patients, with 7 patients not using their pAVF because they were not on dialysis (n = 4), were on peritoneal dialysis (n = 2), and refused to use fistula (n = 1). Fistula maintenance was required in 31.8% (27 of 85) of patients and included fistula dysfunction (21.2%), thrombosis (5.9%), cannulation injury (12.9%), and arm swelling (4.7%). The number of procedures performed per patient per year to maintain function and patency was 0.32 (91 of 288) for years 2–5. The cumulative patency rates were 89.5%, 88.4%, 88.4%, 85.6%, and 82.0% for years 1, 2, 3, 4, and 5, respectively. The functional patency was 91.8% at the end of the study. There were no major complications related to pAVF during the long-term follow-up.ConclusionsPercutaneous fistulae have provided clinically effective and durable access for hemodialysis with low complications. The continued use and evaluation of pAVF are warranted.     

The Pivotal Multicenter Trial of Ultrasound-Guided Percutaneous Arteriovenous Fistula Creation for Hemodialysis Access

Purpose

To evaluate safety and efficacy of arteriovenous fistulas (AVFs) created with a thermal resistance anastomosis device.

Comparison between Surgical and Endovascular Hemodialysis Arteriovenous Fistula Interventions and Associated Costs

Purpose

To compare: (i) rate of arteriovenous fistula (AVF) interventions in both incident and prevalent end-stage kidney disease patients; (ii) their associated costs; and (iii) intervention-free survival between patients with surgical hemodialysis arteriovenous fistula (SAVF) versus those with an endovascularly created fistula (endoAVF).

血液透析之自体动静脉内瘘的CT血管造影初步研究

目的:利用16层CT研究血液透析之自体动静脉内瘘的血管造影.材料和方法:慢性肾衰进行血液透析患者14例,2例肘部内瘘,其余均腕部标准内瘘.采用16层CT机,1mm×16方式,从非患肢前臂静脉进针,非离子型碘造影剂90ml,注射速度3ml/s,延时25～30s开始扫描,数据薄层重建采用低通滤过(FC01),层厚1mm,重建间隔0.8mm,分别完成容积显示、最大强度投影、多层面重建或曲面重建的CT血管造影(CTA).结果:所有病例患肢血管在CTA上均得到良好显示,包括4例掌动脉弓良好显示.流入动脉均未见异常,前臂或肘部的引流静脉闭塞、中断6处,侧支循环明显;吻合口及其后的流出道狭窄19处,包括吻合口狭窄4处、吻合口后近处狭窄6处、其余各处狭窄8处,狭窄可为局限或细长.1例见头臂静脉支架内栓子形成.结论:CTA可以充分显示自体动静脉内瘘及其相关血管,有助于临床相关问题的解释和指导治疗.     

Postcatheterization Femoral Arteriovenous Fistula: Endovascular Treatment with N-Butyl-Cyanoacrylate Embolization

We report a case of an iatrogenic femoral arteriovenous fistula (AVF) in a 67-year-old man presenting with right femoral bruit on the day after sheath removal for cardiac catheterization. This was successfully treated with embolization using N-butyl-cynoacrylate (NBCA) through a coaxial microcatheter. Transcatheter embolization of iatrogenic femoral AVFs with NBCA in selected cases may be a safe and effective treatment in the presence of long fistula tracts. It is then easy to perform in experienced hands and relatively inexpensive.     

Ileocolic Arteriovenous Fistula with Superior Mesenteric Vein Aneurism: Endovascular Treatment

We report a case of a venous aneurysm secondary to an acquired ileocolic arteriovenous fistula in a 64-year-old woman with recurrent abdominal pain and history of appendectomy. The aneurysm was diagnosed by ultrasound and computed tomography. Angiography showed an arteriovenous fistula between ileocolic branches of the superior mesenteric artery and vein. This vascular abnormality was successfully treated with coil embolization.     

Endovascular Revascularization of Chronically Thrombosed Arteriovenous Fistulas and Grafts for Hemodialysis: A Retrospective Study in 15 Patients With 18 Access Sites

The current study retrospectively evaluated whether endovascular revascularization of chronically thrombosed and long-discarded vascular access sites for hemodialysis was feasible. Technical and clinical success rates, postintervention primary and secondary patency rates, and complications were reported. During a 1-year period, we reviewed a total of 924 interventions performed for dysfunction and/or failed hemodialysis vascular access sites and permanent catheters in 881 patients. In patients whose vascular access-site problems were considered untreatable or were considered treatable with a high risk of failure and access-site abandonment, we attempted to revascularize (resurrect) the chronically occluded and long-discarded (mummy) vascular access sites. We attempted to resurrect a total of 18 mummy access sites (mean age 46.6 ± 38.7 months; range 5–144) in 15 patients (8 women and 7 men; mean age 66.2 ± 11.5 years; age range 50–85) and had an overall technical success rate of 77.8%. Resurrection failure occurred in 3 fistulas and in 1 straight graft. The clinical success rate was 100% at 2 months after resurrection. In the 14 resurrected vascular access sites, 6 balloon-assisted maturation procedures were required in 5 fistulas; after access-site maturation, a total of 22 interventions were performed to maintain access-site patency. The mean go-through time for successful resurrection procedures was 146.6 ± 34.3 min (range 74–193). Postmaturation primary patency rates were 71.4 ± 12.1% at 30 days, 57.1 ± 13.2% at 60 days, 28.6 ± 13.4% at 90 days, and 19 ± 11.8% at 180 days. Postmaturation secondary patency rates were 100% at 30, 60, and 90 days and 81.8 ± 11.6% at 180 days. There were 2 major complications consisting of massive venous ruptures in 2 mummy access sites during balloon dilation; in both cases, prolonged balloon inflation failed to achieve hemostasis, but percutaneous N-butyl cyanoacrylate glue seal-off was performed successfully. Percutaneous resurrection of mummy vascular access sites for hemodialysis is technically feasible with high clinical success rates. In selected patients, resurrection of mummy access sites provides long-discarded access sites one more chance to be used for hemodialysis in an effort to preserve potential extremity sites for future access-site placement and to prevent long-term catheter indwelling.     

Endovascular Recanalization of a Thrombosed Native Arteriovenous Fistula Complicated with an Aneurysm: Technical Aspects and Outcomes

Objective

To evaluate the technical aspects and outcomes of endovascular recanalization of a thrombosed native arteriovenous fistula (AVF) complicated with an aneurysm.

Materials and Methods

Sixteen patients who had a thrombosed AVF complicated with an aneurysm (two radiocephalic and 14 brachiocephalic) were included in this study. Recanalization procedures were performed by mechanical thrombectomy using the Arrow-Trerotola percutaneous thrombectomy device and adjunctive treatments. We evaluated dose of thrombolytic agent, underlying stenosis, procedure time, technical and clinical success, and complications. The primary and secondary patency rates were calculated using the Kaplan-Meier analysis.

Results

The thrombolytic agents used were 100000 U urokinase mixed with 500 IU heparin (n = 10) or a double dose of the mixture (n = 6). The thrombi in aneurysms were removed in all but two patients with non-flow limiting residual thrombi. One recanalization failure occurred due to a device failure. Aspiration thrombectomy was performed in 87.5% of cases (n = 14). Underlying stenoses were found in the outflow draining vein (n = 16), arteriovenous anastomosis or juxtaanastomosis area (n = 5), and the central vein (n = 3). Balloon angioplasty was performed for all stenoses in 15 patients. Two patients with a symptomatic central vein stenosis underwent insertion of a stent after balloon angioplasty. Mean procedure time was 116.3 minutes. Minor extravasation (n = 1) was resolved by manual compression. Both technical and clinical success rates were 93.8% (n = 15). The primary patency rates at 3, 6, and 12 months were 70.5%, 54.8%, and 31.3%, respectively. The secondary patency rates at 3, 6, and 12 months were 70.5%, 70.5%, and 47.0%, respectively.

Conclusion

Thrombosed AVF complicated with an aneurysm can be successfully recanalized, and secondary patency can be prolonged with endovascular treatment.     

Thermal Resistance Anastomosis Device for the Percutaneous Creation of Arteriovenous Fistulae for Hemodialysis

Purpose

To evaluate the safety and efficacy of arteriovenous fistula (AVF) creation with a thermal resistance anastomosis device (TRAD).

Arteriovenous Fistula of a Colic Branch of the Superior Mesenteric Artery: Endovascular Therapy

Arteriovenous fistulae (AVF) of the superior mesenteric artery and its branches are exceedingly rare. We report an unusual case of a patient who was found to be symptomatic from such an AVF, with diarrhea and terminal ileal thickening. We describe the findings from magnetic resonance imaging, computed tomography and catheter angiography and discuss the endovascular management.     

Endovascular Treatment of an Aortobronchial Fistula

A 67-year-old man operated on 8 years previously for type B aortic dissection presented with two episodes of massive hemoptysis. An aortobronchial fistula was suspected with spiral computed tomography angiography, and showed a small pseudoaneurysm corresponding to the distal anastomotic site. The patient underwent endovascular stent-graft implantation and is asymptomatic 8 months after the procedure.     

Long-term Results of Endovascular Stent Graft Placement of Ureteroarterial Fistula

Purpose

To evaluate the safety, efficacy, and long-term results of endovascular stent graft placement for ureteroarterial fistula (UAF).

Methods

We retrospectively analyzed stent graft placement for UAF performed at our institution from 2004 to 2012. Fistula location was assessed by contrast-enhanced computed tomography (CT) and angiography, and freedom from hematuria recurrence and mortality rates were estimated.

Results

Stent graft placement for 11 UAFs was performed (4 men, mean age 72.8 ± 11.6 years). Some risk factors were present, including long-term ureteral stenting in 10 (91 %), pelvic surgery in 8 (73 %), and pelvic radiation in 5 (45 %). Contrast-enhanced CT and/or angiography revealed fistula or encasement of the artery in 6 cases (55 %). In the remaining 5 (45 %), angiography revealed no abnormality, and the suspected fistula site was at the crossing area between urinary tract and artery. All procedures were successful. However, one patient died of urosepsis 37 days after the procedure. At a mean follow-up of 548 (range 35–1,386) days, 4 patients (36 %) had recurrent hematuria, and two of them underwent additional treatment with secondary stent graft placement and surgical reconstruction. The hematuria recurrence-free rates at 1 and 2 years were 76.2 and 40.6 %, respectively. The freedom from UAF-related and overall mortality rates at 2 years were 85.7 and 54.9 %, respectively.

Conclusion

Endovascular stent graft placement for UAF is a safe and effective method to manage acute events. However, the hematuria recurrence rate remains high. A further study of long-term results in larger number of patients is necessary.     

64排螺旋CT透析自体动静脉瘘狭窄成像的技术初探

目的探讨64排螺旋CT在血液透析自体动静脉瘘狭窄中血管成像(CTA)的方法和体会。方法在让患者充分了解和愿意配合本检查后,使用64排螺旋CT。患者取俯卧位,患肢上举,高于头部,取健侧肘静脉穿刺,团注对比剂,最大不超过55 ml,流率4～5 ml/s。对比剂注射完毕后立即以相同流率注入20～30 ml生理盐水。CT扫描参数为:层厚0.625 mm,螺距为1.108,螺旋时间0.75 s/r,80 kV和120 mAs。采用自动管电流和Blous Track-ing扫描方式,对21例(男12例,女9例,中位年龄61岁)自体动静脉瘘狭窄的患者行CTA检查。在EBW工作站上采用1 mm层厚行矢、冠和轴位的重组,并进行三维的多平面重组(MPR),曲面重组(CPR),最大密度投影(MIP)和容积再现(VR)以最佳参数和角度显示自体动静脉瘘狭窄的状况。结果本组患者有20例(95%)获得了满意的CTA图像,即狭窄部位清晰可见,病变血管的范围、走行清楚。侧支循环血管清晰。本组21例均为血管超声所发现,其中10例被DSA或手术证实与CTA结果相同。结论要获得良好的自体动静脉瘘CT图像,需与患者良好的沟通,参数配置准确,恰当。其中对比剂的用量和扫描速度的快慢、扫描时间的长短,阈值的设定,为关键因素。     

Preliminary Study On the Native Arteriovenous Fistula (AVF) Stenosis in Hemodialysis Patients with 64 slice Spiral CT Angiography

目的 探讨64排螺旋CT在血液透析自体动静脉瘘狭窄中血管成像(CTA)的方法和体会.方法 在让患者充分了解和愿意配合本检查后,使用64排螺旋CT.患者取俯卧位,患肢上举,高于头部,取健侧肘静脉穿刺,团注对比剂,最大不超过55 ml,流率4～5 ml/s.对比剂注射完毕后立即以相同流率注入20 ～30 ml生理盐水.CT扫描参数为:层厚0.625 mm,螺距为1.108,螺旋时间0.75 s/r,80 kV和120 mAs.采用自动管电流和Blous Tracking扫描方式,对21例(男12例,女9例,中位年龄61岁)自体动静脉瘘狭窄的患者行CTA检查.在EBW工作站上采用1 mm层厚行矢、冠和轴位的重组,并进行三维的多平面重组(MPR),曲面重组(CPR),最大密度投影(MIP)和容积再现(VR)以最佳参数和角度显示自体动静脉瘘狭窄的状况.结果 本组患者有20例(95％)获得了满意的CTA图像,即狭窄部位清晰可见,病变血管的范围、走行清楚.侧支循环血管清晰.本组21例均为血管超声所发现,其中10例被DSA或手术证实与CTA结果相同.结论 要获得良好的自体动静脉瘘CT图像,需与患者良好的沟通,参数配置准确,恰当.其中对比剂的用量和扫描速度的快慢、扫描时间的长短,阈值的设定,为关键因素.     

Endovascular Management of Immediate Procedure-Related Complications of Failed Hemodialysis Access Recanalization

Endovascular procedures are becoming the standard type of care for the management of hemodialysis vascular access dysfunction. As with any type of medical procedure, these techniques can result in procedure-related complications, although the expected number of complications is low. The clinical extent of these complications varies from case to case. Management of these cases depends on the clinical presentation. Major complications such as vein rupture, arterial embolism, remote site bleeding or hematoma, symptomatic pulmonary embolism and puncture site complications necessitating treatment require major therapy. Minor complications such as non-flow compromising small puncture site hematoma or pseudoaneurysms require little or no therapy. It is essential that the interventionist be prepared to manage these complications appropriately when they arise.