Venous Outflow Stenosis of the Brachiocephalic Fistula: A Single Entity, or is the Cephalic Arch Different?

Abstract

Background: Cephalic Arch Stenosis (CAS) is emerging as an important cause of Brachiocephalic Fistula (BCF) failure. The optimal management strategy for dysfunctional AVF as a result of CAS is yet to be defined. Endovascular management is generally employed as first line treatment based upon success in other venous stenosis sites. We compare the outcomes of angioplasty in CAS to other venous stenoses causing BCF dysfunction. Methods: 62 patients with dysfunctional BCF due to venous segment pathology were identified and proceeded to angioplasty. Lesions were categorized anatomically: 19 CAS, 22 venous outflow, 21 swing segment(<3cm of anastomosis). Anastomotic stenoses were excluded. Endovascular intervention was carried out in a standard fashion; 8-10mm balloon angioplasty at the interventionalist’s discretion. Patients were followed prospectively by regular clinical and venous pressure monitoring of the fistula. Re-intervention was performed on clinical suspicion of recurrence. Results: Mean duration of follow-up was 402 days. Patient demographics were comparable across the three groups except a lower incidence of diabetes in the cephalic arch cohort (15.7% vs. 28.2% vs. 25.0%). Swelling and aneurysmal fistulae were more common presenting complaints in CAS (15.7% vs. 2.6% vs. 0%). Mean length of cephalic arch stenosis was shorter(1.6cm vs.3.1cm vs.2.5cm). Primary patency of cephalic arch angioplasty was 68.8%, 43.7% and 31.0% at 3, 6 and 12 months respectively. Primary assisted patency was 87.5%, 81.0% and 43.0%. There was no significant difference in primary or primary assisted patency compared to other outflow stenoses. 2.3 interventions/ patient were required to preserve the access in the CAS cohort vs. 1.1 interventions/ patient for venous outflow stenosis and 1.3 interventions/ patient for swing segment stenoses. Conclusion: CAS bears a different clinical presentation to other venous outflow stenoses. Despite being shorter, and apparently a more attractive target lesion, the hallmark is a requirement for repeated endovascular intervention when compared to other venous stenoses causing BCF dysfunction