Iliac artery-ureteral fistula developing after dilatation and stent placement

A fistula formed between the common iliac artery and the ureter following balloon dilatation of the distal ureter and stent placement in the presence of an ileal conduit. Possible causes are discussed.     

Residual stenosis after conventional balloon angioplasty for hemodialysis shunt failure: treatment with metallic stent placement and post-balloon dilatation

PURPOSE: The usefulness of metallic stent placement and post-balloon dilatation was investigated for patients with residual stenosis after conventional percutaneous transluminal balloon angioplasty (balloon PTA) of dialysis shunt vessels. MATERIALS AND METHODS: Among 92 patients who had received balloon PTA for dialysis shunt vessels, seven patients who showed a residual waist on the balloon even under maximum inflation were enrolled in this study. In these patients with residual stenosis after balloon PTA, we inserted a stent in the residual stenosis, and post-balloon dilatation was immediately applied using the same balloon catheter. RESULTS: After balloon PTA, the average percent diameter stenosis declined to 45.5 +/- 7.30%, and the stenosis was further improved to an average of 19.3 +/- 7.09% after the placement of a stent and the additional balloon PTA. The average percent diameter dilatation of the balloon before the placement of a stent was 65.8 +/- 12.7%, while the average dilatation increased to 84.1 +/- 8.96% after the placement of a stent. Dialysis became possible immediately after the procedure in all cases. CONCLUSION: Metallic stent placement and post-balloon dilatation was effective for patients with residual stenosis after conventional balloon PTA of dialysis shunt vessels.     

Metallic stent placement in patients with recurrent cancer after gastrojejunostomy

PURPOSE: To assess the technical feasibility and clinical effectiveness of placement of expandable metallic stents in patients with recurrent cancer after a gastrojejunostomy. MATERIALS AND METHODS: Data from 39 consecutive patients who had undergone metallic stent placement for recurrent malignant obstruction after a gastrojejunostomy were retrospectively analyzed. Thirty patients underwent a distal gastrectomy with a gastrojejunostomy with (n=10) or without (n=20) jejunojejunostomy, two patients underwent distal gastrectomy with a Roux-en-Y gastrojejunostomy, and seven patients underwent a palliative gastrojejunostomy with (n=5) or without (n=2) jejunojejunostomy. A total of 57 metallic stents were used in this study: four bare stents, 29 partially covered stents, and 24 fully covered stents. Types of obstruction were classified into 12 patterns and types of stent placement were classified into 16 patterns. RESULTS: Stent placement was technically successful in all patients. After stent placement, 35 of the 39 patients (90%) experienced improvement of their symptoms, two showed no change, and the remaining two showed aggravation of symptoms as a result of faulty stent placement. Two patients treated with stent placement only in the afferent loop died of aspiration pneumonia. In one of two patients who underwent stent placement according to pattern 6, afferent loop syndrome occurred 10 days after stent placement and was treated by percutaneous pigtail catheter drainage. Stent migration occurred in four of 24 fully covered stents, but in none of the bare or partially covered stents. Tumor ingrowth occurred in one of four bare stents, tumor overgrowth in one of 29 partially covered stents, and mucosal prolapse in one of 24 fully covered stents; all were treated with a second stent placement. CONCLUSIONS: Placement of expandable metallic stents in patients with recurrent cancer after a gastrojejunostomy seems to be feasible and effective, but accurate knowledge of the type of surgical procedure performed and determination of the pattern of tumor recurrence are important for successful stent placement.     

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.

     

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.

     

Use of a cutting balloon for dilatation of a resistant venous stenosis of a hemodialysis fistula

In a 71-year-old patient with a Brescia-Cimino hemodialysis fistula, high-pressure balloon dilatation failed to open the stenosis completely and a constant waist of the balloon was found. The use of a 3.5-mm coronary cutting balloon (Barath balloon) was helpful in preparing the stenosis for subsequent successful dilatation.     

Percutaneous transluminal balloon angioplasty in stenosis of native hemodialysis arteriovenous fistulas: technical success and analysis of factors affecting postprocedural fistula patency

PURPOSE

We aimed to determine the predictors of technical success and patency after percutaneous transluminal angioplasty (PTA) of de novo dysfunctional hemodialysis arteriovenous fistulas (AVF).

METHODS

We performed a retrospective analysis of first time PTA in 228 patients (129 men, 99 women; mean age, 56.8±14.6 years). Anatomical (location, length, grade, and number of stenoses) and clinical variables (sex, age, prior AVF, diabetes mellitus, AVF age, side, and location) were reviewed.

RESULTS

A total of 330 stenoses were found in 228 patients. PTA was technically successful in 96.3% of the stenoses (n=319). Clinical success was achieved in 97.2% (n=321). Early dysfunction (within six months) was positively correlated with patient age (P < 0.001) and diabetes (P < 0.005). Older age (P < 0.001) and diabetes (P = 0.002) were associated with a lower primary patency rate. Patient age (P < 0.001), presence of diabetes (P = 0.023), length of stenosis (P = 0.003), early recurrence (P = 0.003) and presence of residual stenosis (P = 0.014) were associated with a lower secondary patency rate.

CONCLUSION

Patency of dysfunctional hemodialysis fistulas can be maintained safely with continuous follow-up and repeated interventions without shortening the venous segment by surgical revision. Percutaneous approach to hemodialysis access stenosis is an alternative to the conventional surgical approach and PTA is an effective treatment method for dysfunctional AVF.Hemodialysis, and therefore patent hemodialysis access, is of great importance to patients with end-stage renal disease (ESRD). The preferred type of access in patients undergoing hemodialysis is an arteriovenous fistula (AVF) (1). The Kidney Disease Outcomes Quality Initiative provides evidence-based clinical practice guidelines for all stages of ESRD and reports autogenous AVF as the reference standard for primary vascular access, due to their longevity and low infection rates (2, 3). Sands et al. (4) and Schwab et al. (5) demonstrated a 10-fold increase in thrombosis rate of synthetic polytetrafluoroethylene (PTFE) accesses when compared to AVFs. Despite proven advantages of AVF over PTFE, both types of access eventually fail and contribute to multiple hospital admissions, radiological and surgical interventions, and overall morbidity associated with chronic hemodialysis. Significant stenosis causing access dysfunction is a frequent complication in hemodialysis and requires repeated percutaneous transluminal balloon angioplasty (PTA) to maintain patency (6–9). The patency of PTA is limited, however, with first year primary patency rates ranging between 26% and 62% (6–8). Many factors influencing the patency rate have been studied in previously reported series (7, 8). Our study is the first to investigate the effect of early recurrence on secondary patency.     

经皮血管成形术治疗血液透析动静脉内瘘狭窄或闭塞

目的:探讨经皮血管成形术(PTA)治疗血液透析患者动静脉内瘘狭窄和闭塞的临床效果。方法:对16例动静脉内瘘狭窄和闭塞的血液透析患者行PTA治疗,比较PTA治疗前后的血管造影表现、透析时血流量及静脉压的变化情况。结果:术后血管造影显示狭窄和闭塞的血管扩张、再通,触诊感血管震颤增强。术后第2天透析时血流量升高至200ml/min以上,可完成透析,在血流量为250ml/min时静脉压下降为(110.62±15.71)mmHg;其中2例分别在术后3个月和6个月发生再狭窄,再次行PTA后血流量恢复。所有患者均未出现血管破裂、出血、血栓形成等并发症。结论:PTA是治疗动静脉内瘘狭窄和闭塞的有效、安全、微创的方法,可选择适宜的患者采用。     

Percutaneous transluminal angioplasty for arteriovenous fistula stenosis or occlusion in hemodialysis patients

目的:探讨经皮血管成形术(PTA)治疗血液透析患者动静脉内瘘狭窄和闭塞的临床效果.方法:对16例动静脉内瘘狭窄和闭塞的血液透析患者行PTA治疗,比较PTA治疗前后的血管造影表现、透析时血流量及静脉压的变化情况.结果:术后血管造影显示狭窄和闭塞的血管扩张、再通,触诊感血管震颤增强.术后第2天透析时血流量升高至200ml/min以上,可完成透析,在血流量为250ml/min时静脉压下降为(110.62±15.71)mmHg；其中2例分别在术后3个月和6个月发生再狭窄,再次行PTA后血流量恢复.所有患者均未出现血管破裂、出血、血栓形成等并发症.结论:PTA是治疗动静脉内瘘狭窄和闭塞的有效、安全、微创的方法,可选择适宜的患者采用.     

维持性血液透析患者微炎症状态与动静脉内瘘失功的关系

目的探讨维持性血液透析患者动静脉内瘘失功与机体微炎症反应状态的关系。方法将92例排除了急性炎症反应的维持性血液透析患者分为两组,动静脉内瘘失功组(A组)30例,动静脉内瘘功能正常组(B组)62例,分别检测两组的hs-CRP、IL-6及TNF-α水平并进行比较。结果 A组hs-CRP(7.50±2.32)mg/L、IL-6(70.12±14.63)ng/L、TNF-α(64.65±9.56)ng/L,B组hs-CRP(5.07±3.54)mg/L、IL-6(61.45±9.58)ng/L、TNF-α(54.35±6.98)ng/L,两组比较差异有统计学意义(P<0.05)。结论机体微炎症状态与动静脉内瘘失功密切相关。     

Transvenous embolization and stent placement for an internal iliac arteriovenous fistula with central iliac vein occlusion

The authors present a case of traumatic arteriovenous fistula of the internal iliac vessels treated with attempted surgical ligation of the common iliac artery and external iliac artery. The fistula persisted after the operation, and because the patient received no further treatment for the following 6 years, a venous outflow occlusion also developed as a result of high-flow angiopathy. Because the arterial route was eliminated at previous surgery, the fistula and venous occlusion were percutaneously treated via a transvenous approach.     

球囊扩张联合导管接触溶栓治疗动静脉内瘘狭窄闭塞的手术护理技巧

目的：探讨球囊扩张术联合经导管接触溶栓治疗肾衰竭血液透析患者动静脉内瘘狭窄闭塞的手术护理技巧和注意事项,并评价效果。 方法：回顾性分析我科2014年5月至2017年9月收治的肾衰竭血液透析患者动静脉内瘘狭窄行球囊扩张术及经导管接触溶栓治疗的41例患者资料,总结围手术期的护理经验。 结果：通过及时有效的术中护理配合及心理疏导,本组患者均能耐受介入手术,保障介入手术的顺利进行,手术成功率为90.2%（37/41）。细致的围手术期护理能切实保障患者安全及手术效果。 结论：及时有效的术中配合、心理疏导以及细致的围手术期护理对动静脉内瘘狭窄患者介入手术顺利进行及提高患者治疗期间满意度有重要的意义。     

VascuTrakTM球囊导管在自体动静脉内瘘顽固性狭窄闭塞治疗中的应用

目的 在国内初步报道VascuTrakTM球囊导管治疗血液透析患者自体动静脉内瘘(AVF)非血栓性顽固狭窄闭塞的经验和体会.方法 采用近期在中国上市的新型经皮腔内血管成形术球囊导管——VascuTrakTM球囊导管治疗14例AVF顽固性狭窄闭塞患者,观察分析临床治疗效果,如技术成功率、术中局部疼痛、残余狭窄及并发症发生率等.结果 全部14例患者AVF狭窄闭塞均获即时开通,技术成功率100％.1～6 atm压力下VascuTrakTM球囊全部获得充分扩张,其中1次成功12例(85.7％),2次成功2例(14.3％);腕部无疼痛10例,轻度疼痛4例,难以忍受的剧烈疼痛0例.术后彩色超声复查AVF通畅,残存狭窄＞30％患者0例.术中术后未发生血管夹层、痉挛及急性血栓形成,1例术后出现肱动脉假性动脉瘤,手术修补重建后恢复,与VascuTrakTM球囊治疗无关.结论 VascuTrakTM球囊治疗AVF失效安全有效,近期疗效良好,中远期疗效及通畅率有待进一步随访观察.     

血液透析动静脉内瘘血管狭窄和闭塞的介入治疗

目的探讨经导管溶栓、经皮血管成形术(PTA)治疗血液透析动静脉内瘘狭窄和闭塞的可行性和有效性。方法对25例自体血管血液透析动静脉瘘道狭窄和闭塞患者行血管造影,18例血栓形成闭塞患者经导管尿激酶溶栓治疗,16例血管狭窄行PTA。结果 25例造影显示血栓闭塞18例,单纯性狭窄7例;经溶栓治疗开通16例,即时开通率88.9%(16/18)。溶栓开通16例中9例显示血管狭窄,该9例与单纯性狭窄7例共16例进行了PTA治疗,成功14例,失败2例,术后所有病例未发生肺梗塞、出血等并发症。溶栓完全开通或PTA成功后,即感血管震颤较前明显增强,次日透析时血流量达到250mL/min,可完全满足透析需要。结论经导管溶栓和PTA是治疗动静脉内瘘血栓形成和血管狭窄的安全、有效和微创的方法,经导管溶栓具有较高的开通率;对栓塞伴有血管狭窄的患者,在溶栓的基础上,结合PTA可提高远期开通率。     

Follow-up results after stent placement in failing arteriovenous shunts: A three-year experience

Self-expandable endoprostheses were used in 18 failing arteriovenous shunts after unsuccessful balloon dilatation. Technical success was satisfactory with an early patency in 17 of 18 shunts. Thrombosis right after stenting occurred in three shunts but was successfully treated in two. Followup history revealed recurrent events of reobstruction due either to stent or shunt stenoses or thrombosis. Restenosis within the stented segment was responsible for reobstruction in about half the cases. Although patency was low with 27% at 18-month follow-up, repeated intervention established a shunt survival rate of 77% at 18-month follow-up. Stent placement in AV shunts is useful for overcoming acute problems of balloon dilatation but does not prevent restenosis.     

Factors influencing technical success and outcome of percutaneous balloon angioplasty in de novo native hemodialysis arteriovenous fistulas

Objective

To determine predictors of technical success, dysfunction recurrence and patency after percutaneous transluminal angioplasty (PTA) of de novo dysfunctional hemodialysis arteriovenous fistulas (AVFs).

Methods

Retrospective analysis of first time PTA of 167 AVF in 162 patients (100 men, 66 ± 13 years). Anatomical (location, length, grade and number of stenoses) and clinical variables (sex, age, prior AVF, diabetes mellitus and AVF age, side and location) were reviewed.

Results

217 stenoses or segmental occlusions were treated. Technical success rate (84.4%) was higher in radiocephalic AVF compared to brachial artery–median vein AVF (p = 0.030) and was negatively correlated with initial stenosis (p = 0.049). Dysfunction recurrence was seen in 52.7% and correlated negatively with technical success (p = 0.013) and AVF age (p = 0.008). Early dysfunction (within 6 months) was negatively correlated with AVF age (p = 0.016) and positively with diabetes (p = 0.003). Higher AVF age resulted in higher primary (p = 0.005) and secondary patency rates (p = 0.037–0.005).

Conclusions

Technical success of PTA in hemodialysis AVF is affected by AVF type and initial stenosis and has significant effect on dysfunction recurrence, but not on AVF longevity. Younger AVF has increased risk for (early) recurrent dysfunction and lower patency rates. Patients with diabetes mellitus have higher risk for early dysfunction.     

Combined laser and balloon angioplasty of venous obstructions in patients with insufficient hemodialysis access fistulas

In 19 patients with insufficient hemodialysis access fistulas combined laser and balloon angioplasty of two occlusions and 17 stenoses of the shunt vein was performed. In 13 of those 19 cases the procedure was preceded by balloon angioplasty, which was insufficient because of resistant subintimal fibrosis. After using the pulsed dye laser a complete dilatation was possible in all cases.The new method is a valuable addition to percutaneous interventional techniques in patients with shunt problems, and better long term results may be expected in selected cases. Offprint requests to: E. Gmelin     

肾透析用动静脉内瘘急性血栓置管溶栓的护理

目的总结8例血液透析用动静脉内瘘发生急性血栓,行置管溶栓治疗的护理配合。方法对患者进行局部置管碎栓后,再用尿激酶团注结合微泵持续溶栓。结果患者能积极配合置管溶栓,内瘘均能再通。结论本方法血栓发生时间短,操作简单、不良反应小、效果满意。