Duplex-Guided Repair of Failing or Nonmaturing Arterio-venous Access for Hemodialysis

Abstract

Diagnostic arteriography and balloon angioplasty of failing or nonmaturing arterio-venous (AV) access is based upon using nephrotoxic contrast. Patients not yet on dialysis with borderline renal function with nonmaturing AV accesses or ones with an allergy to contrast media present a therapeutic challenge. We have used duplex scanning as an alternative imaging modality to guide endovascular therapy in 10 cases (9 autologous and 1 prosthetic). Six target AV accesses (60%) were used for dialysis. Number of stenoses ranged from 1 to 5 per AV access. Short access sheath insertion, wire and balloon passage, and inflation were guided by duplex only. Balloon size (5-8 mm in diameter) was chosen based on duplex measurements. Cutting balloons (4 x 20 mm and 5 x 20 mm) were used for dilatation of recoiling lesions in 4 cases. One patient had a self-expanding stent placed under duplex-guidance for recoiling lesion in the junction of the brachial and axillary veins. Angioplasty of failing AV access can be performed under duplex guidance alone. Duplex guidance offers very important advantages of hemodynamic evaluation for recoiling lesions and need for stenting. Avoidance of contrast use for repair of nonfunctioning AV access can be a useful option in patients with renal failure not yet on dialysis or in cases of allergy.