Cutting Balloon Angioplasty in Dialysis Fistulas: Let Us Start to Ask the Right Questions

Abstract

Bhat and coworkers [1] describe the use of cutting balloons in a larger cohort of dialysis fistulas. They found a high technical success and an acceptable follow-up patency compared to conventional balloon angioplasty. Moreover, the results are in line with a number of other publications stating the effectivity and technical safety of cutting balloon angioplasty in dialysis patients [2–6]. However, the more expensive technique of cutting angioplasty has an alternative: the use of high-pressure balloons, with pressures up to 30 atm [7]. Trerotola and coworkers showed, in their retrospective work, that by use of extreme pressures, a high technical success is achievable [7]. Evidence-based knowledge about the use of cutting balloons in dialysis fistulas is scarce, however. In a prospective trial, Karya and coworkers found no advantage of cutting balloons regarding primary patency except for graft-to-vein stenosis [8]. Vesely et al., on the contrary, did not find a significant benefit of cutting angioplasty over conventional balloon angioplasty in the treatment of graftto-vein anastomoses [9]. The author himself is a convinced user of cutting balloons in particular highly resistant stenoses ([20–25 atm) in dialysis fistulas. However, I must admit that there is not yet striking evidence published regarding when and why to use cutting balloons in dialysis fistulas, although my daily practice and gut feeling tell me that highly resistant lesions do benefit from them and the technique is safe. Cutting balloons, however, are expensive, difficult to manufacture, and not very easy to handle. To ensure that we will keep this interesting and—in the eyes of many—important interventional tool in our hands, we have, finally, to start to ask the right questions. It is not surprising that there is no statistical difference between cutting ballons and conventional balloons in a general cohort of dialysis lesions. Patency in these lesions is influenced by a large number of factors, and probably huge cohorts need to be investigated to find a statistical difference—if that is possible. What we need to focus on is determining whether the subgroup of lesions which are resistant to high pressures, 20 atm—which have to be considered technical failures of conventional percutaneous transluminal angioplasty—will benefit from cutting balloon angioplasty regarding patency and whether there is also a long-term advantage over extreme pressure balloon angioplasty. These results, which should be gained in a prospective, randomized, and multicenter fashion, are warranted to guarantee the further availability of the fascinating tool of cutting balloon angioplasty in our hands.