Early Results of Duplex-Guided Transradial Artery Fistuloplasties

Abstract

Although arteriovenous fistulae (AVFs) are the preferred mode of hemodialysis access because of their high patency rates, they are associated with an appreciable rate of nonmaturation. Balloon-assisted maturation (BAM) has been described to treat this issue. BAM is defined as repeated sequential graduated dilatation of the outflow vein. This study aims to evaluate the short-term complications of using the radial artery as an access for BAM procedures and fisutloplasties. Transradial access was used preferentially with multiple lesions in the AVF that were difficult to access with a single venous puncture. Data were collected over 3years on 44 office-based duplex-guided transradial access BAM procedures in 27 patients of whom 19 were men. BAM with ultrasound guidance was performed in 324 cases using a venous puncture during this period. The indication for the procedures was a failure of AVF maturation, and 5 cases were with short segment thrombectomy. All procedures were performed with local anesthesia only. Access site puncture, vessel cannulation, wire placement, and balloon advancement and insufflation were duplex-guided. The radial artery was punctured with ultrasound guidance and a 4-5 French low-profile sheath was placed. After crossing the lesion(s), 5,000 units of heparin was given. The radial artery was used as the access vessel for all procedures except one, in which the brachial artery was used in addition. Vascular injuries were classified based on the postprocedural duplex assessment. All patients had follow-up duplex scans within a week. The average age was 79years (±14 SD, range 39-99years). The types of AVF were 35 radio-cephalic, 1 radio-basilic, 2 brachio-brachial, 2 brachio-cephalic, and 4 brachio-basilic. The number of sites of lesions was 17 on the venous outflow, 7 perianastomotic, and 6 in the radial artery. In the remaining 14 failing AVFs, we were not able to identify any lesion. The balloon size ranged from 3-6mm (28 patients) and 7-12mm (16 patients). The most common injury was outflow vein wall injury (25), the formation of wall hematoma of the outflow vein (11), localized extravasation or rupture at the balloon site (4), spasm of the AVF (3), the formation of a puncture-site hematoma (2), and intimal flap (3). Extravasation was controlled with duplex-guided compression. There were no radial artery thromboses, and all the AVFs were patent on completion duplex and follow-up duplex. These data suggest that the radial artery could be used as a safe access route for BAM procedures with relatively low rates of complication. This approach can be considered as an adjunct in the armamentarium for angioplasty of AVF.