Access Circuit Research Articles

Evaluating the Clinical Outcomes of Drug-Coated Balloon and Conventional Balloon Angioplasty in the Management of Stent Edge Restenosis

Background Coronary stenting is frequently complicated by stent edge restenosis (SER), which causes the artery to re-narrow. Drug-eluting stents (DES), plain balloon angioplasty (POBA), conventional balloon angioplasty (CBA), and drug-coated balloons (DCBs) are possible treatments for SER. Methods This study compared the effectiveness of DCB angioplasty with CBA to treat SER. Eighty patients were randomly assigned to receive either DCB or CBA. At 8th week and 6 months, the primary patency of the target lesion and access circuits were assessed as clinical outcomes. Furthermore, levels of perceived stress were measured by perceived stress scores. Results At 8th week, the perceived stress levels of the DCB group were statistically significantly (<0.05) lower than those of the CBA group. Compared to the CBA group, the DCB group experienced improved outcomes at 6 months in all clinical outcomes. Conclusion DCB angioplasty may be superior to CBA in treating SER. In addition to enhancing vascular access, DCB angioplasty may also enhance mental and general well-being. Keywords Anxiety, Depression, Drug-Coated Balloon Vascular Access, Perceived Stress.

Contrast Venography Versus Intravenous Ultrasound in Hemodialysis Arteriovenous Access Dysfunction

Contrast Venography Versus Intravenous Ultrasound in Hemodialysis Arteriovenous Access Dysfunction

A Randomised Trial Comparing Drug Coated Balloons and Conventional Balloons for the Treatment of Stent Graft Stenosis in Dialysis Vascular Access

Previous studies on arteriovenous fistulas have demonstrated the potential benefit of drug coated balloons (DCBs) in maintaining the patency of dialysis access. However, stenoses involving stent grafts were excluded from these studies. Therefore, the aim was to evaluate the effectiveness of DCBs in treating stent graft stenosis. This was a prospective, single blinded, randomised controlled study. From March 2017 to April 2021, 40 patients with dysfunctional vascular access owing to stent graft stenosis were randomised to treatment with a DCB or conventional balloon. Clinical follow up was scheduled at one, three, and six months, and angiographic follow up was performed six months after the intervention. The primary outcome was angiographic late luminal loss at six months, and secondary outcomes included target lesion and access circuit primary patency at six months. Thirty-six participants completed follow up angiography. The DCB group had a superior mean late luminal loss at six months compared with the control group (1.82 mm ± 1.83 mm vs. 3.63 mm ± 1.08 mm, respectively, p= .001). All 40 patients completed clinical follow up. The DCB group had a superior six month target lesion primary patency compared with the control group [hazard ratio (HR) 0.23, 95% confidence interval (CI) 0.07 - 0.71; p= .005). Additionally, the DCB group had a numerically higher six month access circuit primary patency rate than the control group, although the difference was not statistically significant (HR 0.54, 95% CI 0.26 - 1.11, p= .095). Conventional balloon angioplasty is not durable in stent graft stenosis treatment. Treatment with DCBs provides less angiographic late luminal loss and potentially superior primary patency of the target lesion than treatment with conventional balloons. [ClinicalTrials ID: NCT03360279.].

Management of Thrombosed Dialysis Access Circuits.

Thrombotic occlusion of autologous arteriovenous fistulas or synthetic arteriovenous grafts is a serious adverse event in hemodialysis patients and declotting should be performed before next hemodialysis session, in order to avoid a central venous catheter. Various techniques exist to declot a thrombosed vascular access, including open surgical thrombectomy, catheter-directed thrombolysis and use of different types of percutaneous thrombo-aspiration catheters and mechanical thrombectomy devices. These devices can be categorized as devices with direct wall contact and hydrodynamic devices without direct wall contact. Technical and early clinical outcome results of percutaneous hemodialysis declotting are high and ranging between 70 and 100%; late clinical patency results are much lower related to restenosis or re-thrombosis; these patency results are higher for autologous arteriovenous fistulas compared to synthetic arteriovenous grafts and mainly depend on the combined efficacy of successful thrombectomy and durable treatment of the underlying stenoses, associated with the acute thrombosis.

Prospective, randomized, multicenter clinical study comparing a self-expanding covered stent to percutaneous transluminal angioplasty for treatment of upper extremity hemodialysis arteriovenous fistula stenosis

Use of a covered stent after percutaneous transluminal angioplasty (PTA) was compared to PTA alone for treatment of upper extremity hemodialysis patients with arteriovenous fistula (AVF) stenoses. Patients with AVF stenosis of 50% or more and evidence of AVF dysfunction underwent treatment with PTA followed by randomization of 142 patients to include a covered stent or 138 patients with PTA alone. Primary outcomes were 30-day safety, powered for noninferiority, and six-month target lesion primary patency (TLPP), powered to test whether TLPP after covered-stent placement was superior to PTA alone. Twelve-month TLPP and six-month access circuit primary patency (ACPP) were also hypothesis tested while additional clinical outcomes were observed through two years. Safety was significantly non-inferior while six- and 12-month TLPP were each superior for the covered stent group compared to PTA alone (six months: 78.7% versus 55.8%; 12 months: 47.9% versus 21.2%, respectively). ACPP was not statistically different between groups at six-months. Observed differences at 24 months favored the covered-stent group: 28.4% better TLPP, fewer target-lesion reinterventions (1.6 ± 1.6 versus 2.8 ± 2.0), and a longer mean time between target-lesion reinterventions (380.4 ± 249.5 versus 217.6 ± 158.4 days). Thus, our multicenter, prospective, randomized study of a covered stent used to treat AVF stenosis demonstrated noninferior safety with better TLPP and fewer target-lesion reinterventions than PTA alone through 24 months.

SUPERA stent placement for salvaging early recurrent arteriovenous graft thrombosis after percutaneous transluminal angioplasty: A single-center study.

The aim of this study was to evaluate the patency of the helical interwoven SUPERA stent for salvaging prosthetic arteriovenous (AV) grafts with rapidly recurrent thrombotic occlusion developed within a short time period after successful percutaneous transluminal angioplasty. From December 2019 to September 2021, the data of 20 patients with AV graft who had the SUPERA stent inserted satisfying the following conditions were consecutively collected. (1) More than 1 year has passed since the AV access operation; (2) Thrombotic re-occlusion of AV graft occurred within 3 months after previous successful endovascular treatment; (3) Residual stenosis is greater than 30% after full effacement of balloon angioplasty in the primary lesion. Post-interventional target lesion primary patency (TLPP), access circuit primary patency (ACPP), and secondary patency (SP) were calculated. Primary lesions of early recurrent arteriovenous graft thrombosis were found in 13 patients with graft-vein anastomosis, six patients with intra-graft stenosis, and one patient with outflow vein complications. The lesions showed residual stenosis in 47.4% (interquartile range: 44.1%-55.3%) of patients despite full-effacement balloon angioplasty. Clinical success was achieved in all patients with full-expansion of the stents at the 1-month follow-up. The TLPP was 70.7% and 32% at 6 and 12 months, respectively, and ACPP was 47.5% and 6.8% at 6 and 12 months, respectively. The SP was 76.1% and 57.1% at 6 and 12 months, respectively. No cannulation complications occurred in the six patients with installation inside the graft. No hemodialysis or stent fracture occurred in any patient during the follow-up period. The SUPERA stent may have a role in salvaging AV grafts with early recurrent thrombosis due to its greater radial force and its conformability and can be useful in treating stenosis involving the elbow or axilla, with fair patency and low complication rates.

The Effects of Protrusion into the Outflow Vein on Outcomes of Stent Grafts Used to Treat Cephalic Arch Stenoses in Dysfunctional Brachiocephalic Fistulae

PurposeTo assess long-term patency rates of cephalic arch stent grafts in brachiocephalic fistulae and the importance of device position. Materials and MethodsThis retrospective study reviewed 152 patients with dysfunctional brachiocephalic fistulae and cephalic arch stenosis treated with stent grafts (Viabahn; W. L. Gore) at a single tertiary center between 2012 and 2021. The median age was 67.5 years (range, 25–91 years), and the median follow-up period was 637 days (range, 3–3,368 days). A grading system of protrusion was applied: (a) Grade 0, no protrusion; (b) Grade 1, perpendicular; and (c) Grade 2, in-line protrusion. Subsequent fistulograms were available in 133 (88%) of the 152 patients and were assessed for central vein stenosis within 10 mm of the stent graft. Clinical records were assessed for sequelae of stent graft protrusion. Stent graft primary and cumulative circuit patencies were calculated using the Kaplan-Meier method. ResultsProtrusion was documented in 106 (70%) stent grafts—56 Grade 1 and 50 Grade 2. Central vein stenosis was seen in 1 (2%) case of no protrusion (Grade 0) and 38 (40%) cases of protrusion (P < .0001). There was no significant difference in stenosis between Grade 1 and 2 protrusion (P = .15). No adverse clinical sequelae occurred in 147 (97%) patients. Eight patients had a new access subsequently formed in the same arm, and 3 of these 8 patients developed symptoms due to the previous stent graft protrusion (all Grade 2). The primary patency rates of the stent-grafts at 6 and 12 months were 73% and 50%, respectively. The cumulative access circuit patency rates at 1, 2, and 5 years were 84%, 72%, and 54%, respectively. ConclusionsThis study demonstrated that protrusion of a cephalic arch stent graft into the central vein is safe and only clinically relevant when a subsequent ipsilateral access is created.

Angioplasty of Dysfunctional Dialysis Fistula or Graft with Resveratrol-Excipient and Paclitaxel-Coated Balloon Improves Primary Patency Rates Compared to Plain Angioplasty Alone.

In this prospective randomized single-blinded study (reg. ISRCTN11414306), 76 patients with a dysfunctional dialysis fistula or graft due to a single de novo or recurrent stenosis in the access circuit were randomized to receive either conventional PTA (POBA) as a standard of care (n = 38) or PTA + adjunctive PTA with a drug-coated (paclitaxel-resveratrol matrix) SeQuent® Please OTW balloon (n = 38, DCB). Patients were scheduled for follow-up PTA at 3, 6, 9, and 12 months. The time of clinically driven target-lesion reintervention rate (primary patency rate) after the index procedure was analyzed using the log-rank test. The primary patency rates at 12 months after the index procedure were 17% (DCB) vs. 11% (POBA). At 3 months, they were 87% vs. 74%, at 6 months they were 53% vs. 26%, and at 9 months they were 22% vs. 11%. The hazard ratio for DCB was 0.55 (95%CI 0.32 to 0.95). The median time needed for target-lesion reintervention was longer in the DCB group (181 days) than in the conventional PTA group (98 days, p = 0.019). We conclude that PTA with the paclitaxel-resveratrol drug-coated SeQuent® Please OTW balloon in patients with de novo or recurrent stenosis in dialysis arteriovenous fistulas or grafts prolongs the time needed for target lesion reintervention and improves primary patency rates in the first year after the index procedure.

Endovascular salvage of thrombosed haemodialysis vascular access.

Background: Haemodialysis access thrombosis is associated with significant morbidity and access abandonment rates, for which endovascular salvage is a well described treatment option. This study aimed to evaluate the outcomes of endovascular salvage procedures of thrombosed vascular access circuits and identify factors influencing outcomes. Patients and methods: Retrospective review of 328 consecutive procedures performed over 10 years at our institution between January 2010 and December 2019. Patient demographics, access circuit characteristics, procedure details and outcome data were collected. Kaplan-Meier survival curves were used to estimate patency rates and Cox multivariate regression analysis to identify factors affecting outcomes. Results: Technical and clinical success rates were 87.8% and 75.9% respectively. The primary, primary assisted and secondary patency rates at 6 months were 42.2%, 46.7% and 59.1%; and at 12 months were 23.4%, 28.3% and 41.8% respectively. Median access circuit survival was 9.2 months. Major complication rate was 5.2% including 3 procedure-related deaths. Native AVF, lower time from thrombosis to intervention and pharmacomechanical thrombectomy using AngioJetTM predicted positive outcomes. Previous thrombectomy within 3 months and residual thrombus at completion were associated with poorer outcomes. Age and hypertension predicted higher complication rates. Conclusions: This is one of the largest single center series of endovascular salvage of thrombosed haemodialysis access and demonstrates that endovascular treatment is effective and provides durable access circuit survival. Careful patient screening is essential to optimize outcomes.

Sirolimus-coated balloon angioplasty in maintaining the patency of thrombosed arteriovenous graft: 1-year results of a prospective study.

A prospective, pilot study was designed to test the feasibility of using sirolimus-coated balloon (SCB) to treat graft vein junction of thrombosed arteriovenous graft (AVG) following successful pharmacomechanical thrombectomy. The present report provides the 1-year results of this study. This is a 1-year follow-up of a single, prospective, single-arm study that was conducted from 2018 to 2019 in 20 patients who presented to a tertiary institution with thrombosed AVG. The recruited patients received SCB angioplasty at the graft-vein junction following successful endovascular thrombectomy of a thrombosed AVG. One year after recruitment, there were three deaths, one AVG revision, and one AVG explantation among the participants recruited. The outcomes of 15 subjects at 1-year following the index procedure obtained from electronic medical records were re-examined. The 1-year access circuit primary patency rate was 40%, while assisted primary and secondary patency rates were 46.7% and 73.3%, respectively. A total of 16 interventions (4 angioplasties, 12 thrombectomies) were performed in 9 patients over the 12 months. Four AVGs were abandoned. The median number of interventions per patient was 1 (0-3) per year. Using Kaplan-Meier analysis, the mean estimated post-intervention access circuit primary patency was 230 (95% CI: 162-300) days, while access circuit assisted primary patency was 253 (95% CI: 187-320) days, and access circuit secondary patency was 292 (95% CI: 230-356) days. Sub-group analysis did not show a significant difference in the mean estimated primary patency between AVG with de novo and recurrent stenosis (245 days, 95% CI: 151-339 vs 210 days, 95% CI: 113-307; p = 0.29). SCB may help sustain the patency of thrombosed AVG following successful thrombectomy.

Treatment of intragraft stenosis in hemodialysis grafts with Supera stents: A retrospective study.

To report the patency rates after implantation of an interwoven nitinol stent to salvage failing arteriovenous grafts (AVGs) caused by intragraft stenoses. Between May 2018 and May 2020, 21 Supera stents were placed in 20 patients (18 women; mean age: 79.9 years) who had a failing AVG due to repeat intragraft stenoses. Recurrent AVG dysfunction with same intragraft stenosis within 3 months after first time angioplasty was a criterion for stenting. Those with concurrent treatment for other lesions were excluded. The technical success rate was 100%. Intragraft stenoses were treated at a median of 19.7 (interquartile range: 6-36) months after graft creation. Access circuit primary patency rates after stent placement were 84% and 35% at 6 and 12 months, respectively. Access circuit secondary patency rates were 100% at 6 and 12 months and 89% at 18 months. Only one patient presented with graft failure due to proximal drainage vein occlusion. The target lesion patency rates were 100% at 6 months and 75% at 12 months. The rate of reintervention for intragraft lesion was 0.15 procedures per year. Stent distortion did not occur under regular cannulation. The interwoven nitinol stent is a promising treatment for failing AVGs with recurrent intragraft stenoses. The 1-year access circuit primary, secondary, and target lesion patency rates were acceptable, with a low reintervention rate. Stent fracture does not occur in areas of needle puncture.

IN.PACT AV Access Trial: Economic Evaluation of Drug-Coated Balloon Treatment for Dysfunctional Arteriovenous Fistulae Based on 12-Month Clinical Outcomes

PurposeTo study, from a U.S. payer’s perspective, the economic consequences of drug-coated balloon (DCB) versus standard percutaneous transluminal angioplasty (PTA) use for the treatment of stenotic lesions in dysfunctional hemodialysis arteriovenous fistulae. Materials and MethodsCost differences between DCBs and PTA at year 1 and beyond were calculated via 2 methods. The first approach used the mean absolute number of trial-observed access circuit reinterventions through 12 months (0.65 ± 1.05 vs 1.05 ± 1.18 events per patient for DCBs and PTA, respectively) and projected treatment outcomes to 3 years. The second approach was based on the trial-observed access circuit primary patency rates at 12 months (53.8% vs 32.4%) and calculated the cost difference on the basis of previously published Medicare cost for patients who maintained or did not maintain primary patency. Assumptions regarding DCB device prices were tested in sensitivity analyses, and the numbers needed to treat were calculated. ResultsUsing the absolute number of access circuit reinterventions approach, the DCB strategy resulted in an estimated per-patient savings of $1,632 at 1 year and $4,263 at 3 years before considering the DCB device cost. The access circuit primary patency approach was associated with a per-patient cost savings of $2,152 at 1 year and $3,894 at 2.5 years of follow-up. At the theoretical DCB device reimbursement of $1,800, savings were $1,680 and $2,049 at 2.5 and 3 years, respectively. The one-year NNT of DCB compared to PTA was 2.48. ConclusionsEndovascular therapy for arteriovenous access stenosis with the IN.PACT AV DCB can be expected to be cost-saving if longer follow-up data confirm its clinical effectiveness.

IN.PACT AV Access Randomized Trial: 12-Month Clinical Results Demonstrating the Sustained Treatment Effect of Drug-Coated Balloons

PurposeTo present the 12-month outcomes of the IN.PACT AV Access Study, a prospective, single-blind trial enrolling participants with obstructive de novo or restenotic native upper extremity arteriovenous dialysis fistula lesions treated with a drug-coated balloon (DCB) or percutaneous transluminal angioplasty (PTA). Materials and MethodsAfter successful high-pressure PTA, participants at 29 international sites were randomized 1:1 to treatment with an IN.PACT AV DCB (n = 170) or standard uncoated PTA (n = 160). Outcomes at 12 months include target lesion primary patency (TLPP), defined as freedom from clinically driven target lesion revascularization or access circuit thrombosis; access circuit primary patency; number of reinterventions; and adverse events involving the access circuit. ResultsAt 12 months, TLPP was 63.8% (90/141) in the DCB group compared with 43.6% (61/140) in the PTA group (P < .001). The total number of reinterventions required to maintain TLPP through 360 days was 93 in the DCB group and 144 in the PTA group, with a 35.4% reduction in reinterventions when DCB was used. Access circuit thrombosis occurred in 2.9% (4/138) of the participants in the DCB group and in 6.2% (8/129) of those in the PTA group (P = .19). Time to TLPP was assessed using a multivariable analysis to identify the factors associated with loss of patency. The treatment device was the independent predictor with the largest effect, with a hazard ratio of 0.42 (95% confidence interval, 0.29–0.60; P < .001). ConclusionsTLPP was statistically significantly higher with DCBs than with standard PTA at 12 months, demonstrating the sustained and superior effectiveness of this device for the treatment of dysfunctional arteriovenous dialysis fistulae.

Prospective First-in-Human Study of the Merit WRAPSODY Endovascular Stent Graft for Treatment of Access Circuit Outflow Stenosis in Hemodialysis Patients

The aim of this study was to evaluate the safety and effectiveness of the WRAPSODY stent graft in the treatment of outflow and central (brachiocephalic and/or subclavian) stenoses or occlusions in the arteriovenous venous circuit of persons requiring dialysis for end-stage renal disease.

Drug-eluting balloon (DEB) versus plain old balloon angioplasty (POBA) in the treatment of failing dialysis access: A prospective randomized trial.

ObjectiveTo compare the efficacy of angioplasty using drug-eluting balloons (DEB) compared with plain old balloon angioplasty (POBA) to reduce the rate of restenosis.MethodsThis prospective, single-centre, single-blinded, 1:1 randomized, clinical trial enrolled patients that had primary or restenotic lesions in native upper extremity arteriovenous (AV) fistulas or at the graft-venous anastomosis. Patients were randomized to angioplasty with a POBA or a DEB. The primary effectiveness endpoints were freedom from target lesion revascularization (TLR) and functional status of access circuit at 12 months.ResultsA total of 42 (28 male, 14 female; age range, 42–83 years) patients were enrolled. Patients were followed for 12 months. No significant differences were detected between the POBA and DEB groups regarding total number of TLR procedures (31 versus 36, respectively), freedom from TLR (3 versus 4, respectively) and functional status of the access circuit at 12 months (14 of 20 patients [70%] versus 17 of 22 patients [77%], respectively).ConclusionThis clinical trial did not demonstrate any significant differences between DEB angioplasty and standard balloon angioplasty when treating dysfunctional haemodialysis access.

Prospective, Multicenter Clinical Study of the Covera Vascular Covered Stent in the Treatment of Stenosis at the Graft-Vein Anastomosis of Dysfunctional Hemodialysis Access Grafts

PurposeTo study the use of the self-expanding Covera covered stent for the treatment of stenotic lesions at the venous anastomosis of hemodialysis arteriovenous grafts (AVGs). Materials and MethodsA total of 110 patients with AVG venous anastomotic stenosis of ≥50% and access dysfunction were treated at 14 centers in the United States using percutaneous transluminal angioplasty followed by covered stent placement. The primary end points were 30-day safety and 6-month target lesion primary patency (TLPP). The secondary measures included access circuit primary patency, circuit cumulative patency, and the number of reinterventions through 24 months. ResultsFreedom from a primary safety event at 30 days was 96.4% while the 6-month TLPP rate was 70.3%. Seventy-five patients completed 24-month follow-up (68.2%). The TLPP rates were 54.2% at 365 days and 36.9% at 730 days while the access circuit primary patency rates were 16.7% at 365 days and 7.8% at 730 days (Kaplan-Meier analysis). The access circuit cumulative patency rates were 85.4% at 12 months and 73.6% at 24 months. The number of reinterventions to maintain the patency of the access circuit was 3.6 ± 3.1 at 24 months (1.6 ± 1.9 at the target lesion). ConclusionsUse of the Covera covered stent for hemodialysis graft-vein anastomotic stenosis provided a safe treatment option with a TLPP rate of 70.3% at 6 months and TLPP and cumulative access circuit patency rates of 36.9% and 73.6% at 2 years.

Drug-Coated Balloons for the Dysfunctional Vascular Access: An Evidence-Based Road Map to Treatment and the Existing Obstacles.

An underlying stenosis within the venous limb of a hemodialysis access circuit is the main etiology for graft and fistula dysfunction as well as other symptoms such as arm, breast, and neck swelling. Treatment options for both peripheral and central venous stenoses include plain old balloon angioplasty, angioplasty with drug-coated balloons, and stenting. This article discusses the current evidence for the use of drug-coated balloon angioplasty in this patient population.

Endovascular Management of Thrombosed Dialysis Vascular Circuits.

A functional hemodialysis vascular access is the lifeline for patients with end-stage kidney disease and is considered a major determinant of survival and quality of life in this patient population. Hemodialysis therapy can be performed via arteriovenous fistulas, arteriovenous grafts, and central venous catheters (CVCs). Following dialysis vascular access creation, the interplay between several pathologic mechanisms can lead to vascular luminal obstruction due to neointimal hyperplasia with subsequent stenosis, stasis, and eventually access thrombosis. Restoration of the blood flow in the vascular access circuit via thrombectomy is crucial to avoid the use of CVCs and to prolong the life span of the vascular access conduits. The fundamental principles of thrombectomy center around removing the thrombus from the thrombosed access and treating the underlying culprit vascular stenosis. Several endovascular devices have been utilized to perform mechanical thrombectomy and have shown comparable outcomes. Standard angioplasty balloons remain the cornerstone for the treatment of stenotic vascular lesions. The utility of drug-coated balloons in dialysis vascular access remains unsettled due to conflicting results from randomized clinical trials. Stent grafts are used to treat resistant and recurrent stenotic lesions and to control extravasation from a ruptured vessel that is not controlled by conservative measures. Overall, endovascular thrombectomy is the preferred modality of treatment for the thrombosed dialysis vascular conduits.

Long-term Results of Interwoven Nitinol Stents to Treat the Radiocephalic Anastomotic Arteriovenous Fistula Stenosis

Introduction: Juxta-anastomotic stenosis (JXAS) is a common problem afflicting the arteriovenous fistula (AVF). This study aimed to evaluate the safety and long-term efficacy of an interwoven nitinol stent (Supera, Abbott Vascular, Santa Clara, CA, USA) in the treatment of radiocephalic AVF JXAS. Methods: A single-center, retrospective, observational study was conducted of patients with failing AVF due to JXAS treated with an interwoven nitinol stent. End points included JXAS target lesion primary patency, access circuit primary patency, assisted access circuit primary patency, and endovascular intervention rate (EIR). Results: Sixty patients were treated with a Supera stent in the JXAS between February 2014 and March 2020. One patient was excluded (AVF used for illicit drug use), leaving 59 patients (67.8% male, mean age 66.9 ± 11.4 years [range: 40–84]) with typical medical comorbidities. Overall, 45.8% of patients had previous AVF intervention. The stent was inserted with a 100% technical success rate with a mean follow-up of 729.6 ± 456.0 days (range: 5–2182 days). Juxta-anastomotic stenosis target lesion primary patency was 68.2 ± 6.6%, 53.3 ± 7.5%, and 46.2 ± 8.1% at 12, 24, and 36 months, respectively. The EIR was .64 (0–3.29) procedures/patient/year, after which the assisted access circuit primary patency rate was 94.3 ± 3.2% at 12, 24, and 36 month time points. Three thrombosed circuits occurred which were all successfully salvaged with no difference in patency by indication for procedure and no AVFs lost/abandoned out to 3 years. Avoidance of stent post-dilatation and the presence of stent mal-apposition were associated with improved primary patency, and reduced EIR, which may suggest an importance in vessel preparation prior to stent implantation. Conclusion: Interwoven nitinol stent treatment of the failing AVF with JXAS results in promising 3 year JXAS patency, with a low rate of endovascular re-intervention for those circuits developing restenosis. All AVFs were maintained over 3 years, demonstrating this treatment allows for long-term radiocephalic AVF vascular access.

Brachial artery transposition versus catheters as tertiary vascular access for maintenance hemodialysis: a single-center retrospective study

Some hemodialysis patients are not suitable for creation of an arteriovenous fistula (AVF) or arteriovenous graft (AVG). However, they can receive a tunneled cuffed central venous catheter (tcCVC), but this carries risks of infection and mortality. We aimed to evaluate the safety and effectiveness of brachial artery transposition (BAT) versus those of tcCVC. This retrospective study evaluated hemodialysis patients who underwent BAT or tcCVC placement because of severe heart failure, hand ischemia, central venous stenosis or occlusion, inadequate vessels for creating standard arteriovenous access, or limited life expectancy. The primary outcome was whole access circuit patency. Thirty-eight patients who underwent BAT and 25 who underwent tcCVC placement were included. One-year patency rates for the whole access circuit were 84.6% and 44.9% in the BAT and tcCVC groups, respectively. The BAT group was more likely to maintain patency (unadjusted hazard ratio: 0.17, 95% confidence interval: 0.05–0.60, p = 0.006). The two groups did not have significantly different overall survival (log-rank p = 0.146), although severe complications were less common in the BAT group (3% vs. 28%, p = 0.005). Relative to tcCVC placement, BAT is safe and effective with acceptable patency in hemodialysis patients not suitable for AVF or AVG creation.