Abstract
BackgroundTreatment of cephalic arch stenosis (CAS) with standard plain old balloon angioplasty (POBA) in dysfunctional arteriovenous fistulas (AVF), is associated with early re-stenosis and higher failure rates compared to other lesions. Paclitaxel-coated balloons (PCB) may improve patency rates. This is a retrospective cohort study. Patients who underwent POBA or PCB for CAS over a 3-year period were included. Outcomes compared were circuit primary patency rates (patency from index procedure to next intervention), circuit primary assisted-patency rates (patency from index procedure to thrombosis), and target lesion (CAS) patency rates (stenosis > 50%) at 3, 6 and 12 months.ResultsNinety-one patients were included. Sixty-five (71.4%) had POBA, while 26 (28.6%) had PCB angioplasty. There were 62 (68.1%) de-novo lesions. CAS was the only lesion that needed treatment in 24 (26.4%) patients. Circuit primary patency rates for POBA versus PCB groups were 76.2% vs. 60% (p = 0.21), 43.5% vs. 36% (p = 0.69) and 22% vs. 9.1% (p = 0.22) at 3, 6 and 12-months respectively. Circuit assisted-primary patency rates were 93.7% vs. 92% (p = 1.00), 87.1% vs. 80% (p = 0.51) and 76.3% vs. 81.8% (p = 0.77), whilst CAS target lesion intervention-free patency rates were 79.4% vs. 68% (p = 0.40), 51.6% vs. 52% (p = 1.00) and 33.9% vs. 22.7% (p = 0.49) at 3, 6 and 12-months respectively. Estimated mean time to target lesion intervention was 215 ± 183.2 days for POBA and 225 ± 186.6 days for PCB (p = 0.20).ConclusionTreatment of CAS with PCB did not improve target lesion or circuit patency rates compared to POBA.
Highlights
Treatment of cephalic arch stenosis (CAS) with standard plain old balloon angioplasty (POBA) in dysfunctional arteriovenous fistulas (AVF), is associated with early re-stenosis and higher failure rates compared to other lesions
Circuit primary patency rates for POBA versus Paclitaxel-coated balloons (PCB) groups were 76.2% vs. 60% (p = 0.21), 43.5% vs. 36% (p = 0.69) and 22% vs. 9.1% (p = 0.22) at 3, 6 and 12-months respectively
The causes of stenosis at the cephalic arch have not been clearly elucidated, with various postulated contributing factors including: increased blood flow and pressures resulting in neotintimal hyperplasia, extrinsic compression by the deltopectoral and claviculopectoral fascia, morphology of the cephalic arch, and the angle of the cephalic-axillary vein junction with increased turbulent flow, and increased number of valves in the cephalic vein resulting in increased turbulent flows (Sivananthan et al 2014)
Summary
Treatment of cephalic arch stenosis (CAS) with standard plain old balloon angioplasty (POBA) in dysfunctional arteriovenous fistulas (AVF), is associated with early re-stenosis and higher failure rates compared to other lesions. The causes of stenosis at the cephalic arch have not been clearly elucidated, with various postulated contributing factors including: increased blood flow and pressures resulting in neotintimal hyperplasia, extrinsic compression by the deltopectoral and claviculopectoral fascia, morphology of the cephalic arch, and the angle of the cephalic-axillary vein junction with increased turbulent flow, and increased number of valves in the cephalic vein resulting in increased turbulent flows (Sivananthan et al 2014) These factors have contributed to the occurrence and recurrence of the lesion, and dialysis circuit primary patency and assisted-primary patency rates remain less than ideal with plain old balloon angioplasty (POBA) alone. There is a need for a longer term treatment solution for the cephalic arch stenosis
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