Clinical Outcome of Overlapping Stents in Hemodialysis Access

Abstract

Endovascular stents have recently been shown to extend access patency in thrombosed and stenotic arteriovenous grafts. Given this improved patency, stent placement has outpaced balloon angioplasty in hemodialysis (HD) access interventions. However, concern remains over localized corrosion and increased neointimal hyperplasia of overlapping stents in the access circuit and whether this promotes premature stent failure. This is a retrospective analysis of HD patients referred for access dysfunction during a 2-yr period. Using a prospectively collected, vascular access database, we identified 76 patients seen for follow-up angiography due to access dysfunction after stent placement. We compared the outcomes of overlapping vs. non-overlapping stents in measured primary assisted patency and mean percent luminal diameter as a marker of lesion severity. The two groups did not differ significantly in demographics or comorbid conditions. Only gender had a significant discrepancy between the two groups, with 65.5% vs.42.9% male (p=0.01) in the overlapping vs. non-overlapping stent groups, respectively. The mean percent luminal stenosis was found to be 83.7 ± 17.3 and 85.5 ± 12.6 (p=0.55) for the overlapping vs. non-overlapping stent groups, respectively. For overlapping and non-overlapping stents, 30-day primary patency was 94% and 89%, respectively, 60-day primary patency was 77% and 63%, respectively, and 90-day primary patency was 68% and 50%, respectively. Using multiple regression analysis, no risk factors were identified to be associated with the severity of luminal stenosis. No identifiable risk factors were found to be associated with improved primary patency. In particular, overlapping vs. non-overlapping stents were not identified as a statistically significant factor influencing primary (assisted) patency (hazards ratio 0.60; 95% CI 0.34 to 1.06; p>0.05). This study provides evidence that the theoretical concern of metal on metal corrosion and increased neointimal hyperplasia that can be seen with overlapping stents does not play a significant clinical role.