Central vein obstruction in hemodialysis patients: results of radiological and surgical intervention.

BACKGROUND/AIMS: Symptomatic central venosus obstruction (CVO) in dialysis patients with arteriovenous fistulas (AVFs) leads to significant morbidity and patient inconvenience. We evaluated the results of surgical and radiological interventional treatment of symptomatic central venous obstruction. METHODS: Clinical data, site and length of vein obstruction, type and outcome of intervention were obtained from patient records. Patency rates of radiological and surgical treatment were calculated using Life Table survival analysis. RESULTS: In 28 patients with VH, 45 interventions (percutaneous intervention 30; surgical reconstruction 10; AVF closure five) were performed. Mean vessel obstruction length was 4.9 cm, mainly localized in the subclavian vein (55%). Initial clinical success rate of PTA and surgery was 92%, with complications after percutaneous transluminal angioplasty (PTA) on six occasions. Restenosis after PTA was observed in 39%. One-year primary and secondary patency after PTA was 50 and 63%, respectively. One-year primary patency after surgical reconstruction was 75%. CONCLUSION: Symptomatic CVO in dialysis patients with AVFs can be treated with a high success rate through radiological intervention. Surgical reconstruction is an appropriate alternative method in case of failed PTA.     

Outcome of endovascular intervention for infrainguinal vein graft stenosis

Assisted graft patency rate following revision of a graft stenosis is far better than that following thrombectomy of an occluded graft. Graft revision by endovascular means has been proposed as a suitable alternative to more invasive surgery. This study reports our experience with endovascular treatment of vein graft stenosis. Between December 1992 and September 2000, percutaneous transluminal balloon angioplasty (PTA) was performed on 90 vein graft stenoses in 87 infrainguinal vein bypass grafts identified by routine graft duplex scan (peak systolic velocity, PSV > 300 cm/sec). All 90 stenoses treated by PTA were retrospectively analysed for stenosis-free patency rate (life-table analysis). Re-stenosis was defined by PSV exceeding 300 cm/sec at the same site of the vein graft where a stenosis was dilated.Ninety vein graft stenoses (72 primary stenoses and 18 recurrent stenoses) in 33 femoropopliteal (above knee), 30 femoropopliteal (below knee) and 24 femorotibial vein bypass grafts were treated by PTA. The timing of PTA ranged from one to 252 months (mean, 23.9 months) from the initial surgery. Cumulative stenosis-free patency rate after PTA was 55.8% at 6 months, 54.0% at one year and 45.0% at three years. Stenosis-free patency rate at six months was significantly lower for revision of recurrent stenosis (25.9%) than for primary stenosis (61.6%) (P = 0.01). The revision of duplex scan detected vein graft stenosis with endovascular intervention was associated with an acceptable stenosis-free patency rate. However, recurrent stenosis treated by PTA had a significantly inferior outcome. Direct surgical revision would be more appropriate for recurrent lesions.     

Venovenostomy for Outflow Venous Obstruction in Patients with Upper Extremity Autogenous Hemodialysis Arteriovenous Access

Outflow venous obstruction is a common problem in patients with autogenous upper extremity hemodialysis access. Surgical revision to divert blood flow into the patent vein is sometimes possible to restore unobstructed flow. The result of this type of procedure is not yet well known. The purpose of this report is to describe our experience with outflow venovenostomy (VV) to salvage dysfunctional autogenous upper extremity arterial venous access (AVF) threatened by venous outflow obstruction in hemodialysis-dependent patients. All patients who underwent VV procedures between September 1999 and October 2004 were reviewed. Data regarding patient demographics, comorbidities, procedure indications, perioperative complications, as well as postoperative AVF function and patency were gathered from patient charts and dialysis records. A total of 11 patients underwent VV in the study period. The median age of the AVF prior to VV was 14 months, with a range of 4-45 months. Two patients had radial cephalic AVF, and they had VV done in the antecubital fossa. Nine patients had brachial cephalic AVF. Seven of them underwent cephalic vein transposition VV, while two patients had basilic vein transposition. Functional AVF was achieved after 1 month in 10 out of 11 patients. Five patients had no further access interventions, four patients required angioplasty at the VV site to maintain access function, and one patient had access infection requiring surgical revision during follow-up. One patient never achieved access function. Postintervention assisted functional patency was 90% ± 9.5% at 39 months. Median follow-up after VV was 16 months. Outflow VV is a viable surgical option for selected patients with failing AVF due to venous outflow obstruction.Presented at the Twenty-sixth Annual Meeting of the Canadian Society for Vascular Surgeons, Quebec City, Quebec, Canada, October 22, 2004.     

Obese and non-obese hemodialysis patients have a similar prevalence of functioning arteriovenous fistula using pre-operative vein mapping

AIMS: The arteriovenous fistula (AVF) is the preferred hemodialysis access. Subset analyses of both the HEMO and DOPPS studies have shown that obese hemodialysis patients have a lower prevalence of functioning AVF. Doppler ultrasound may increase the prevalence of functioning AVF in obese subjects. PATIENTS AND METHODS: The effect of pre-operative vein mapping employed between 10/01/98 and 12/08/00 on the prevalence of functioning AVF in a single university hemodialysis program was studied. Preoperative ultrasound was performed to study venous and arterial systems on both arms. RESULTS: There were 50 obese patients, defined as bodymass index (BMI) > or = 27 kg/m2, and 130 patients with a lower BMI. The groups were similar in mean age and diabetes prevalence. The obese group had statistically significantly more females 34/50 versus 61/130 with p = 0.01. There was no statistically significant difference between the vein mapping parameters studied in the two BMI groups, including mean mid-forearm cephalic vein diameter, distal radial artery peak systolic velocity and subclavian vein patency. No obese patient required venography. There was no significant difference between the number of functioning AVF in both groups (22/50 obese, 48/130 lower BMI, p = 0.24). CONCLUSIONS: Pre-operative vein mapping is associated with a similar prevalence of functioning AVF in obese and lower BMI patients. Pre-operative ultrasound screening is a useful tool to promote AVF placement in obese patients.     

Frequency of critical stenosis in primary arteriovenous fistulae before hemodialysis access: Should duplex ultrasound surveillance be the standard of care?

OBJECTIVE: Increasing use of primary arteriovenous fistulae (pAVFs) is a desired goal in hemodialysis patients (National Kidney Foundation /Dialysis Outcome Quality Initiative guidelines). However, in many instances, pAVFs fail to adequately mature due to ill-defined mechanisms. We therefore investigated pAVFs with color duplex ultrasound (CDU) surveillance 4 to 12 weeks postoperatively to identify hemodynamically significant abnormalities that may contribute to pAVF failure. METHODS: From March 2001 to October 2003, 54 upper extremity pAVFs were subjected to CDU assessment before access. A peak systolic velocity ratio (SVR) of >/=2:1 was used to detect >/=50% stenosis involving arterial inflow and venous outflow, whereas an SVR of >/=3:1 was used to detect >/=50% anastomotic stenosis. CDU findings were compared with preoperative vein mapping and postoperative fistulography when available. RESULTS: Of 54 pAVFs, there were 23 brachiocephalic, 14 radiocephalic, and 17 basilic vein transpositions. By CDU surveillance, 11 (20%) were occluded and 14 (26%) were negative. Twenty-nine (54%) pAVFs had 38 hemodynamically significant CDU abnormalities. These included 16 (42%) venous outflow, 13 (34%) anastomotic, and 2 (5%) inflow stenoses. In seven (18%), branch steal with reduced flow was found. In 35 of 54 (65%) pAVFs, preoperative vein mapping was available and demonstrated adequate vein size (>/=3 mm) and outflow in 86% of cases. Twenty-one fistulograms (38%) were available for verifying the CDU abnormalities. In each fistulogram, the arterial inflow, anastomosis, and venous outflow were compared with the CDU findings (63 segments). The sensitivity, specificity, and accuracy of CDU in detecting pAVF stenoses >/=50% were 93%, 94%, was 97%, respectively. CONCLUSIONS: Before initiation of hemodialysis, an unexpectedly high prevalence of critical stenoses was found in patent pAVFs using CDU surveillance. These de novo stenoses appear to develop rapidly after arterialization of the upper extremity superficial veins and can be reliably detected by CDU surveillance. Turbulent flow conditions in pAVFs may play a role in inducing progressive vein wall and valve leaflet intimal thickening, although stenoses may be due to venous abnormalities that predate AVF placement. Routine CDU surveillance of pAVFs should be considered to identify and correct flow-limiting stenoses that may compromise pAVF long-term patency and use.     

Cutting balloon angioplasty in hemodialysis arteriovenous fistula stenosis resistant to conventional balloon angioplasty

Objective To investigate the efficacy and safety of cutting balloon angioplasty for the treatment of hemodialysis arteriovenous fistula stenosis resistant to conventional percutaneous transluminal angioplasty (PTA). Methods The patients with arteriovenous fistula stenosis who had suboptimal results (residual stenosis ＞30%) by conventional PTA from December 2011 to February 2015 were enrolled. All the patients received cutting balloon angioplasty were rechecked every three months. Results A total of 25 patients with age of (60.7±12.9) years had suboptimal PTA results. Eleven patients with native arteriovenous fistula (AVF) and 14 patients with graft fistula (AVG) underwent cutting PTA for 30 times. The technical success rate was 86.7% and clinical success rate was 100%. The diameter stenosis pre-procedural and post-procedural of cutting PTA was (1.7±0.6) mm and (4.5±0.8) mm respectively (P＜0.05). Six patients had multiple lesions and the stenosis consisted of 21 outflow venous, 6 graft-to-vein anastomosis, 6 cephalic arch, 2 artery and 1 puncture hole stenosis. The primary access patency at 3 and 6 months for AVF group were 70.0% and 10.0%, while for AVG group the figures were 64.3% and 7.1% (P＞0.05). The secondary access patency at 3 and 6 months for AVF group were 70.0% and 30.0%, while for AVG group the figures were 85.7% and 64.3% (P＞0.05). The follow-up time was (8.1±7.3) months. The restenosis rate was 64.0%. Cutting PTA failed to achieve technical success for four times, of whom 2 patients required graft stent implantation and 2 patients required ultra-high-pressure balloons angioplasty to finally achieve technical success. The median survival time of fistula was 173 days. Conclusions Cutting balloon angioplasty have well short-term patency and safety in arteriovenous fistula stenosis resistant to conventional PTA, especially for calcified lesion or "balloon waist". Although it could provide a satisfied long patency by recurrent PTA, the use of cutting balloon would be not advocated as the first-line treatment for fistula stenosis. The efficacy superiority of cutting balloon between AVF and AVG, as well as the cost-effect comparison between cutting balloon and high-pressure balloon, remains unclear, the verification of which requires large-sampled, prospective and randomized studies.     

Long-term outcomes of primary angioplasty and primary stenting of central venous stenosis in hemodialysis patients

INTRODUCTION: Central (superior vena cava, brachiocephalic, or subclavian) venous stenoses are a major impediment to long-term arteriovenous access in the upper extremities. The optimal management of these stenoses is still undecided. The purpose of this study was to determine the outcomes of primary angioplasty (PTA) vs primary stenting (PTS) in a dialysis access population at a tertiary referral academic medical center. METHODS: A database of consecutive hemodialysis patients undergoing endovascular treatment for central venous stenosis was developed for the period 1995 through 2003. This database was retrospectively reviewed. Vessels exposed to either primary high-pressure balloon angioplasty or primary stenting were examined. Vessels undergoing stenting after failed or suboptimal angioplasty were defined as failures at the time of stenting despite the potential continued patency upon completion of stenting. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Cox proportional hazards analysis was performed for time-dependent variables. Data are presented as mean +/- standard deviation where appropriate. RESULTS: PTS was used to treat 26 patients (35% male; average age, 57 +/- 15 years) with 26 central venous stenoses, and 47 patients (45% male; average age, 57 +/- 18 years) with 49 central venous stenoses were treated with PTA. The PTS group underwent 71 percutaneous interventions per stenosis (average, 2.7 +/- 2.4 interventions), and the PTA group underwent 98 interventions per stenosis (average, 2.0 +/- 1.6 interventions). The PTS group hemodialysis access site was an average of 1.0 +/- 1.3 years old at the time of the initial intervention, and the hemodialysis access in the PTA group was an average of 1.1 +/- 1.2 years old. Primary patency was equivalent between groups by Kaplan-Meier analysis, with 30-day rates of 76% for both groups and 12-month rates of 29% for PTA and 21% for PTS (P = .48). Assisted primary patency was also equivalent (P = .08), with a 30-day patency rate of 81% and 12-month rate of 73% for the PTA group, vs PTS assisted patency rates of 84% at 30 days, and 46% at 12 months. Ipsilateral hemodialysis access survival was equivalent between groups. CONCLUSIONS: Endovascular therapy with PTA or PTS for central venous stenosis is safe, with low rates of technical failure. Multiple additional interventions are the rule with both treatments. Although neither offers truly durable outcomes, PTS does not improve on the patency rates more than PTA and does not add to the longevity of ipsilateral hemodialysis access sites.     

Impact of ultrasonographic vascular mapping on constructing autogenous arteriovenous fistulas for permanent hemodialysis access?

PURPOSE: We used high resolution ultrasonography to identify usable veins and arteries in the forearm for creation of autogenous arteriovenous fistulas (AVF) for permanent hemodialysis access. The effect of preoperative vascular mapping followed by intraoperative controls on the outcome of AVF should be reported. METHODS: study subjects were adults referred for primary permanent hemodialysis access between January 2001 and November 2002. In all patients sonographic assessment was performed before surgical evaluation. A feeding artery was considered adequate if the diameter was more than 1.5 mm, the vein more than 2.0 mm. All AVF were controlled by intraoperative sonographic measurements of PSV and diameter of the fistula-vein. RESULTS: AVF were placed in 94.1% of all patients. The early failure rate of AVF was 6.3%. Primary patency rate of AVF after 24 hours: 93.7%, after 30 days: 91.4%, after 3 months: 86.9%, preliminary patency rate after 1 year: 70.1%. No unsuccessful surgical explorations were performed. 85.5 % of AVF were constructed as forearm fistulas. Suboptimal vessels (artery < 2.0 mm, vein < 3.0 mm) were used in 31.3% of patients. Patency rates did not differ in this subgroup. In 2 patients synthetic grafts were placed because of non-maturation of AVF. In 15 patients the AVF had to be cannulated by experts for 3 to 6 months. 50.0% of all AVF were constructed in diabetic patients. Patency rates were equal to that of non-diabetic patients. No patient suffered on signs of steal-syndrome. CONCLUSION: the assessment of forearm vessels by high resolution sonographic vascular mapping helps to find the optimal location for constructing an arteriovenous wrist fistula in almost all patients needing a permanent hemodialysis access. The aggressive approach to the creation of autogenous fistulas could be realized without unsuccessful surgical explorations and with a minimal early failure rate, a high maturation rate including patients with diabetes mellitus and no signs of steal-syndrome     

球囊扩张成形术处理透析用动静脉内瘘狭窄性病变及短中期结果

目的:探讨球囊扩张成形技术在治疗血液透析用动静脉内瘘(AVF)狭窄的临床效果。方法:回顾性分析2014年5月—2015年12月间采用球囊扩张成形技术治疗的31例血液透析用AVF狭窄性病变患者的临床资料。结果:31例患者中,男18例,女13例;桡动脉-头静脉内瘘27例,桡动脉-贵要静脉内瘘2例,尺动脉-贵要静脉内瘘2例;均接受球囊扩张技术治疗。28例(90.3%)获得技术上的成功,围手术期无患者死亡。1例患者术后出现动脉穿刺处假性动脉瘤,1例患者术后出现AVF血栓形成,1例患者出现前臂皮下血肿,其他所有患者AVF恢复通畅并能够以正常流量进行血液透析治疗。术后随访3~12个月,3、6、12个月初次通畅率分别为92.9%,75.0%,50.0%。结论:球囊扩张成形术处理AVF狭窄性病变微创、安全,是AVF狭窄性病变的合理治疗方法,但其中长期疗效仍有待于进一步改善。     

Surgical and endovascular intervention for infrainguinal vein graft stenosis

Purpose: The purpose of this study was to evaluate the stenosis-free patency of open repair (vein-patch angioplasty, interposition, jump grafting) and percutaneous transluminal balloon angioplasty (PTA) of 144 vein graft stenoses that were detected during duplex scan surveillance after infrainguinal vein bypass grafting. Methods: Patients who underwent revision of an infrainguinal vein bypass graft were analyzed for type of vein conduit, vascular laboratory findings leading to revision, repair techniques, assisted graft patency rate, procedure mortality rate, and restenosis of the repair site. Results: The time of postoperative revision ranged from 1 day to 133 months (mean, 13 months). One hundred eighteen primary and 26 recurrent stenoses (peak systolic velocity, >300 cm/s) in 52 tibial and 35 popliteal vein bypass grafts were identified by means of duplex scanning. The repairs consisted of 77 open procedures (vein-patch angioplasty, 28; vein interposition, 33; jump graft, 9; primary repair, 3) and 67 PTAs. No patient died as a result of intervention. Cumulative assisted graft patency rate (life-table analysis) was 91% at 1 year and 80% at 3 years. At 2 years, cumulative assisted graft patency rate was comparable for saphenous vein grafts (reversed, 94%; in situ, 88%; nonreversed, 63%) and alternative vein grafts (89%). Stenosis-free patency rate at 2 years was identical (P = .55) for surgical intervention (63%) and endovascular intervention (63%) but varied with type of surgical revision (P = .04) and time of intervention (<4 months, 45%; >4 months, 71%; P = .006). The use of duplex scan–monitored PTA to treat focal stenoses (<2 cm) and late-appearing stenoses (>3 months) was associated with a stenosis-free patency rate that was 89% at 1 year. After intervention, the alternative vein bypass grafts necessitated twice the reinterventions per month of graft survival (P = .01). Bypass graft to the popliteal versus infrageniculate arteries, site of graft stenosis (vein conduit, anastomotic region), and repair of a primary versus a recurrent stenosis did not influence the outcome after intervention. Conclusion: The revision of duplex scan–detected vein graft stenosis with surgical or endovascular techniques was associated with an excellent patency rate, including when intervention on alternative vein conduits or treatment of restenosis was necessary. When PTA was selected on the basis of clinical and duplex scan selection criteria, the endovascular treatment of focal vein graft stenosis was effective, durable, and comparable with the surgical revision of more extensive lesions. (J Vasc Surg 1999;29:60-71.)     

Saphenous Vein Loop to Femoral Artery Arteriovenous Fistula: <Emphasis Type="SmallCaps">A P</Emphasis>ractical <Emphasis Type="SmallCaps">A</Emphasis>lternative

Secondary to central venous stenosis or thrombosis, alternate sites for permanent hemodialysis need to be explored. The authors experience with the greater saphenous vein to common femoral artery loop arteriovenous fistula (GSV-CFA AVF) is presented. A retrospective review was performed of 4 women and 3 men with a mean age of 52.7 (range, 44-68) years. The mean number of prior access procedures was 3.85 (range, 1-5). Duplex ultrasound showed the greater saphenous vein (GSV) to be at least 3 mm in diameter. Perioperatively, no acute occlusion or significant steal syndrome developed. Groin wound complications (57.1%) resolved with local wound care and selectively antibiotic administration. Six patients developed mild to moderate edema, which required knee-high compression stockings. The mean follow-up was 15 (range, 9-24) months. Mean primary patency was 7 months, primary assisted patency was 15 months, and secondary patency was 16 months. The fistula was functional for hemodialysis in 71.4% (5/7). All patients developed stenoses within the GSV loop, with a mean of 3.0 balloon angioplasties per fistula. Three secondary surgical procedures were performed (two pseudoaneurysm repairs, one vein patch angioplasty). The GSV did not increase significantly in diameter. Use of a GSV-CFA AVF for dialysis access has acceptable results for alternate-site hemodialysis access. Secondary procedures were common. Factors recognized to be important for success were an adequate-sized GSV preoperatively, positioning of the GSV loop, and patient body habitus.     

Arteriovenous fistula reconstruction in patients with kidney allograft failure

Abstract: Background:  Kidney recipients with failing allograft function face the vascular access problem again before returning to hemodialysis. An autologous arteriovenous fistula (AVF), according to the recent Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines, is the optimal vascular access and the use of prosthetic grafts and catheters should be limited. The objective of this study was to assess the feasibility of AVF reconstruction in patients reentering hemodialysis after kidney allograft failure.
Materials and methods:  Two hundred and forty-one transplant recipients reentered hemodialysis between 1990 and 2005. Before kidney transplantation, 221 patients had a functioning AVF on the forearm. Fistula reconstruction was attempted in 112 (51%) patients because of AVF thrombosis. Three strategies were applied according to forearm vein patency: a new radial-cephalic fistula, a radial-perforating vein fistula, or a radial-basilic forearm transposition was created.
Results:  Forearm AVFs were successfully reconstructed in 85 of the 112 patients (73%). The primary patency of the reconstructed AVFs was 57.6% and 44% at 12 and 24 months. Secondary patency was 64.9% and 54.9% at 12 and 24 months, respectively.
Conclusions:  The reconstruction of an old, thrombosed AVF is possible in kidney recipients returning to dialysis, even if the time from thrombosis to fistula repair is a few years.     

Balloon dilatation versus surgical revision of infra-inguinal autogenous vein graft stenoses: long-term follow-up

Although infra-inguinal autogenous vein graft stenoses may be treated by balloon dilatation (PTA) or surgical revision, the optimal approach is undefined. Over the last 7 years 24 PTA procedures were performed on 37 vein graft stenoses in 19 grafts. Graft stenoses were diagnosed from 2 to 72 (mean = 17.3) months after implantation. PTA was successfully completed in 23 (96%) of the 24 procedures including 18 (95%) of the primary, and 5 (100%) of the secondary procedures. Recurrent vein graft stenosis or graft thrombosis developed in 12 (67%) grafts from 3 to 47 (mean = 12.5) months after primary PTA. Long-term patency after primary PTA was 69% at 6, 29% at 12, and 22% at 36 months; secondary patency was 81% at 6, 45% at 12, and 27% at 36 months. During the same period vein graft stenosis in 7 fem-pop and 2 fem-tib grafts were surgically revised with an initial success rate of 100%, and 2 (22%) complications. Four (44%) of these grafts occluded from 1-17 (mean 6.2) months after repair, yielding a primary 5-year patency of 62%. Although vein graft stenosis may be safely, effectively, and repeatedly treated with PTA, long-term durability appears to be superior after surgical revision.     

A ten-year experience with one hundred fifty failing or threatened vein and polytetrafluoroethylene arterial bypass grafts.

Between Jan. 1, 1980, and Dec. 31, 1989, 2187 infrainguinal revascularization procedures were performed. In 130 of these cases with patent bypasses, hemodynamic deterioration was suspected, and urgent arteriography was performed. Twenty additional patients with aortofemoral, femorofemoral, or axillofemoral bypasses demonstrated hemodynamic deterioration. In 93% of failing grafts the condition was suspected because of recurrent symptoms or changes in the pulse examination. Two hundred eighty-five high-grade stenotic or occlusive lesions were identified in inflow arteries, outflow arteries, within the graft, or at proximal or distal anastomoses associated with these 150 grafts. One hundred sixty-one (57%) of these lesions were in patients with failing vein grafts; 115 (40%) were in patients with failing polytetrafluoroethylene (PTFE) grafts; and 9 (3%) were associated with failing composite vein/PTFE grafts. Stenotic lesions less than 5 cm in length were initially treated with percutaneous transluminal balloon angioplasty (PTA). Occlusive lesions, stenoses greater than 5 cm in length, and PTA failures were treated surgically. The overall 6-year cumulative secondary patency rate for failing grafts was 65%, and the limb salvage rate was 75%. The extended patency rate after the first intervention in the failing state was 56% at 5 years. The 5-year secondary patency rate for grafts initially treated with PTA (58%) was not significantly different (p = 0.25) from that for grafts treated initially with surgery (71%). Percutaneous transluminal angioplasty was effective for inflow stenoses of the iliac, femoral, and popliteal arteries and for some outflow lesions.(ABSTRACT TRUNCATED AT 250 WORDS)     

Vascular rupture during angioplasty of hemodialysis raft-related stenoses

Purpose: To retrospectively determine the incidence and outcome of angioplasty-induced ruptures that occurred during treatment of hemodialysis graft-related stenoses. Materials and Methods: During a five year period 1222 patients with dysfunctional or thrombosed polytetrafluoroethylene (PTFE) hemodialysis grafts underwent angioplasty procedures at our institution. Angioplasty-induced vascular ruptures occurred in 24 (2.0%) patients. The locations of these ruptures were: basilic vein (10), venous anastomosis (7), cephalic vein (5), brachial vein (1) and intragraft (1). The mean length of the treated stenoses was 2.4 centimeters. Results: Manual compression was used to treat the vascular rupture in ten patients. One patient was treated with endovascular balloon tamponade and one patient underwent stenting of the rupture site. Despite the rupture, 15 patients had completion of the angioplasty procedure. In nine patients the procedure was abandoned due to persistent stenosis at the rupture site. There were no major complications as a result of these ruptures. Follow-up was available in ten of these patients. All ten underwent at least one successful hemodialysis treatment. In five of these patients the hemodialysis graft failed within 30 days after the rupture. The mean primary patency following rupture in the ten patients with follow-up was 87.5 days (range 5 - 225 days). Conclusion: The incidence of angioplasty-induced vascular rupture of hemodialysis-related stenoses is low and despite the injury, the majority (62%) of procedures can be completed. However, in our experience the long-term patency of the vascular access was suboptimal.     

Late symptomatic venous stenosis in three hemodialysis patients without previous central venous catheters

It is well known that catheters placed in the subclavian or internal jugular veins may develop stenosis in the vein in which the catheter lies. Because the arteriovenous fistula (AVF) relies on good venous outflow, patients with ipsilateral central venous stenosis are subject to the malfunctioning of AVF. Until now, no data were published on patients showing central vein stenosis (CVS) without a previous central venous catheter (CVC) or a pacemaker. In this article, we report on 3 hemodialysis patients manifesting CVS ipslateral to AVF. None of these patients previously had undergone CVC. The stenosis observed had characteristics and symptoms similar to those observed in stenoses consequent to CVC. We concluded that CVS also may occur in subclavian or axillary veins proximal to a working AVF in hemodialysis patients who have never had a CVC and in the absence of compressive phenomena.     

Arm vein reconstruction for limb salvage: long-term outcome.

A series of 42 consecutive patients undergoing infrainguinal vascular reconstruction for limb salvage using vein harvested from the arm were followed prospectively to determine the long-term graft patency and stenosis rates. Vein harvested from the arm ('arm vein') was used for secondary or tertiary reconstruction in 22 patients (52.4%). The outflow was to a single calf vessel in 37 grafts (88.1%). The cumulative primary, primary assisted and secondary graft patency rates were 35.6%, 49.6% and 59.5% at 2 years, respectively, and the limb salvage rate was 69.0% at 2 years. Eight grafts developed stenoses detected by a graft surveillance programme. Six stenoses were dilated successfully with percutaneous transluminal angioplasty (PTA) and one was treated with an interposition vein graft. Bypass using arm vein is time-consuming and technically demanding as multiple anastomoses are often required. Arm vein grafts, however, have no greater incidence of stenosis than long saphenous vein grafts and these stenoses may be dilated with PTA with good results. The long-term outcome suggests that an arm vein graft is an important treatment option in the absence of the long saphenous vein.     

Use of short PTFE segments (<6 cm) compares favorably with pure autologous repair in failing or thrombosed native arteriovenous fistulas

OBJECTIVE: The re-establishment of patency in a stenosed or thrombosed native arteriovenous fistula (AVF) is fundamental to regaining adequate hemodialysis through the same cannulable vein. Many surgeons have been reluctant to use even small segments of synthetic grafts in AVF revisions because of a perception that these would lead to poor results; however, studies comparing various treatment options are scarce. This study compared the use of short (<6 cm) polytetrafluoroethylene (PTFE) segments with pure autologous repair in stenosed or thrombosed native fistulas. METHODS: The cumulative postintervention primary patency rates of two groups of hemodialysis patients receiving different surgical revision operations of their vascular accesses were prospectively compared. Group I (n = 30) comprised patients who presented with stenosed or thrombosed native fistulas and received short (2 to 6 cm) interposition PTFE grafts placed after the stenosed or thrombosed outflow vein segment was resected. These short PTFE grafts were not used for cannulation. Group II (n = 29) comprised patients who presented with dysfunctional or failed AVFs and underwent various types of pure autogenous corrections. AVF dysfunction or thrombosis was detected with clinical examination and color duplex ultrasound scanning. In all cases, on-table arteriography-fistulography was performed before surgical repair. Access adequacy was assessed in all patients postoperatively after the first puncture and every month thereafter (mean follow up 16.7 months). RESULTS: No statistically significant difference in patency was observed between the two groups. Postintervention cumulative patencies were 100%, 88%, and 82% for group I and 90%, 82%, and 71% for group II at 6, 12, and 18 months, respectively ( P = .8). CONCLUSIONS: Short (<6 cm) interposition PTFE segments used for the revision of failing or failed AVFs compare favorably to purely native repair and do not alter the autologous behavior of the initial access. These short PTFE revisions resulted in satisfactory midterm primary patency without further consumption of the venous capital by harvesting segments of vein from other locations and without compromising more proximal access sites. This practice is recommended and is justified as part of an aggressive access salvage policy addressed by many authors so far.     

Hemodialysis arteriovenous access: detection of stenosis and response to treatment by vascular access blood flow

BACKGROUND: Hemodialysis access to the circulation is best provided by native and synthetic arteriovenous fistulae (AVF and AVG). Thromboses caused by venous outflow stenoses prevent the long-term use of AV access. This pilot study was performed to evaluate the ability of ultrasound dilution-derived access blood flows to detect AV access stenosis and to evaluate the response to treatment. METHODS: This pilot study was a single-center, prospective observational intervention trial. The monitoring technique used was ultrasound dilution access blood flow measurements performed monthly and after any intervention. Screening criteria for interventions were decrements in access flow of 20% when the flow value fell under 1000 mL/min or absolute flow of <600 mL/min. The primary intervention when flow criteria were met was biplanar venography of the access with percutaneous transluminal angioplasty (PTA) of detected stenoses. Stenoses unresponsive to PTA were sent for surgical revision. Access thrombosis was considered a study ending event. RESULTS: Baseline access flow at study entry for AVF was 919 and 1237 mL/min for AVG. Sequential measurement of AV access flow detected AV access stenosis. PTA and surgical revision significantly restored AV access flow back toward the baseline flow measurement. Failure to restore access flow by at least 20% following intervention occurred in 14% of AVF and 21% of AVG PTA attempts. Transluminal angioplasty, once successfully performed, was required at a mean of 5.8-month intervals in order to maintain AVG flow. In contrast, AVF flow was restored for a much longer period of time following angioplasty (11.4 month follow-up at the time of study end). Compared with historic controls, which used venous dialysis pressure as the primary monitoring technique, the overall (AVF-AVG) thrombosis rates improved from 25 to 16% per patient year, and AVF thrombosis rates improved from 16 to 7% per patient year. When flow was not successfully restored, thrombosis ensued. Eight of 10 thrombosis episodes were predicted based on inability to improve access flow either as a result of stenosis treatment failure or unsuccessful referral for treatment. CONCLUSION: Sequential measurement of AV access flow is an acceptable means of both monitoring for the development of access stenoses and assessing response to therapy. PTAs of AVF are more durable than PTAs of AV grafts.     

Allogenous vein graft as vascular access for hemodialysis - lost battle?

Purpose: The purpose of this paper is to assess a long-term outcome of allogenous vein grafts (ALVG) as vascular access for hemodialysis. Materials and methods: For nearly eight years (between 9/2002 and 9/2011) a total of 78 patients with 112 ALVGs were involved in the study. The register included 46 women and 32 men, mean age 66.1 ± 11.2 years; range 20-88 years. The patient database was retrospectively reviewed and statistical processing was performed. Results: Almost all ALVGs were treated by PTA or surgically, very often repeatedly. The number of radiologic interventions was 316, the number of surgical procedures 31. Mean follow-up time was 795 days, range 28-3522 days. Thirty-five patients died of unrelated causes, nineteen with functional graft, fourteen patients were lost to follow-up. Forty ALVGs failed for various reasons, mostly because of occlusion. Only one patient underwent successful renal transplantation, no patient converted to peritoneal dialysis. Thirty-seven ALVGs remain correctly functioning. Primary patency rates at 6, 12, and 24 months were 81 ± 5%, 63 ± 5%, and 34 ± 2% respectively. Secondary patency rates at 6, 12, and 24 months were 96 ± 2%, 82 ± 4%, and 65 ± 5% respectively. Conclusions: Allogenous vein grafts, in spite of the high number of necessary radiologic and surgical interventions and reinterventions, show acceptable clinical usability and durability, comparable with other types of prosthetic grafts.