Comparison of Stenting and PTA for Central Venous Stenosis In Hemodialysis Patients

Abstract

Central vein occlusion is a common cause of morbidity in patients with upper extremity hemodialysis (HD) access sites and a history of ipsilateral indwelling central lines. We analyzed the results of two percutaneous treatments, balloon angioplasty (PTA) and stenting (S) that were used to relieve symptomatic venous occlusion (arm edema, pain) and improve dialysis efficiency (venous pressure and recirculation fraction). Group I consisted of 26 patients (13 men, 13 women, mean age = 62 ± 14.3), with de novo lesions (innominate = 5, subclavian = 21) who underwent PTA. Group II consisted of 13 patients from Group I who underwent stent implantation (6 Palmaz stents, 7 Wallstents) for failed PTA due to suboptimal angioplasty results (n = 5) or restenosis (n = 8). We retrospectively compared the acute and long-term clinical success and restenosis rates in these two treatment groups. Acute success was defined as resolution of symptoms and resumption of dialysis. Restenosis was defined as >50% stenosis by angiography. Long-term success @ mean follow-up 14 months was defined as continued dialysis without symptomatic venous occlusion or dialysis graft failure.balloon to prevent cerebral emboli. Six symptomatic patients had 7 PTAs (6 carotids, 1 vertebral). Pt. # Angioplasty Technique Transcrania Doppler Stenosis Pre→Post Complications Stenosis 3m F/U 1 Protected 73 emboli 90%→20% none 10% 2 Protected 40 emboli 90%→0% none 0% 3 Active Perf. no window 95%→0% none 0% 4 Active Perf. 10 emboli 99%→0% none 0% 5 Active Perf. no window 99→0% hemorrh→death 6 Standard no window 100%→30%→ none pending (vertebral) stent→0% Active Perf. 70%→dissec, none pending (carotid) 20%→stent→0% Maintenance of cerebral perfusion during PTA by “active” perfusion and cardiac pacing allows prolonged balloon inflations which minimize residual stenosis; when feasible, TCD monitoring is a valuable adjunct. Ongoing studies with more patients will elucidate the value of this approach for carotid angioplasty.