Cephalic Arch Research Articles

Promising results of stent graft placement for cephalic arch stenosis after repeated failure of angioplasty in patients on hemodialysis

ObjectiveCephalic arch stenosis (CAS) causes repeated dysfunction and failure of arteriovenous access. Percutaneous transluminal angioplasty is the standard initial treatment for CAS, but its outcome is unsatisfactory. This study aimed to evaluate the outcome of stent graft placement for CAS in patients on hemodialysis.MethodsA retrospective chart review from a tertiary medical center was performed in patients receiving stent graft placement for CAS between January 2012 and 2016. Patency was analyzed using the Kaplan–Meier method.ResultsTwenty-one patients received stent graft placement for CAS. Technical and clinical success rates were 100%. Primary target lesion patency was 95% (95% confidence interval [CI], 86%–100%), 76% (95% CI, 58%–94%), and 43% (95% CI, 22%–64%) at 3, 6, and 12 months, respectively. No significant difference in patency was observed between the arteriovenous fistula and arteriovenous graft groups. Assisted primary patency was 95% (95% CI, 86%–100%), 71% (95% CI, 52%–91%), and 57% (95% CI, 36%–78%) at 3, 6, and 12 months, respectively. Secondary patency was 100% at 3, 6, and 12 months.ConclusionsAfter repeated failed angioplasty for cephalic arch stenosis, patients on hemodialysis who receive stent graft placement have effective and durable outcomes.

Advances in Endovascular Salvage.

Endovascular salvage plays an important role in dialysis access care. Angioplasty using standard high- and ultrahigh-pressure balloon is the mainstay of therapy, while the use of cutting balloons and balloons designed to deliver pharmacologically active agents to the site of recurrent stenosis is demonstrating improved performance for specific targets that have to be further defined. Stents and stent grafts are additional tools for use at access segments predisposed for inward remodeling such as the cephalic arch or basilic swing point. The juxta-anastomotic segment has particular relevance in maturation of autogenous accesses as well as maintenance of access flow volume. Depending on the location of the access in the forearm or upper arm, and which artery is feeding into the access vein, any type of balloon angioplasty and stent or stent graft placement may be used to establish and maintain patency. Successful management of dialysis access options relies on preservation of venous real estate during the chronic kidney disease phase of kidney disease as well as on knowledgeable evaluation of arm veins and the access by physical examination, bed side ultrasound, and angiographic studies.

Recanalisation of an axillary vein occlusion jailed by a migrated cephalic arch stent-graft using the TruePath chronic total occlusion drilling device

BackgroundStent placement in the cephalic arch is being used with increasing frequency. Late complications of bare metal and stent grafts in dialysis access, in particular stent migration, are often under-reported and can lead to compromise of future dialysis circuits.Case presentationA 52-year-old man developed acute arm swelling 2 days after creation of a left arm brachio-basilic arteriovenous graft. The axillary vein was found to be jailed by a previously deployed cephalic arch stent graft which had migrated into the subclavian vein. There was failure to cross through the fabric of the stent graft using conventional chronic total occlusion wires and techniques. A TruePath device was used successfully to cross through the fabric of migrated cephalic arch stent graft and recanalise the short subclavian-axillary vein occlusion.ConclusionThe adapted use of a drilling chronic total occlusion device to drill through the fabric of migrated stent graft was performed successfully to allow complete recanalisation of the occluded axillary vein.

Surgical Treatment of Cephalic Arch Stenosis through Rotation of the External Jugular Vein

The percutaneous transluminal balloon angioplasty or cephalic vein transposition is the treatment for cephalic arch stenosis. In some cases, rotation of the external jugular vein may be a good option for the cephalic arch problems. We describe a new technique to treat cephalic arch stenosis. The technique enables the cephalic arch and subclavian vein to be bypassed altogether through the rotation of the external jugular vein. It consists of 3 small incisions, thus causing minimal surgical damage.

Percutaneous Costoclavicular Bypass for Thoracic Outlet Syndrome and Cephalic Arch Occlusion in Hemodialysis Patients.

To report results of percutaneous costoclavicular bypass for symptomatic thoracic outlet or cephalic arch occlusion in patients with arteriovenous fistula. A retrospective review of percutaneous costoclavicular bypass patients between 2014 and 2018 was performed. Stent grafts were placed subcutaneously over the clavicle from the fistula outflow (axillary or cephalic vein) into a jugular vein or collateral. The procedures were performed in patients who had exhausted or were not candidates for balloon dilation or intravascular stent placement. Technical success was 100% (9/9) with resolution of symptoms in all patients. Indications were arm swelling in 67% (6/9), fistula dysfunction in 22% (2/7), and 1 enlarging aneurysm. The fistula outflow was cephalic in 67% (6/9) and axillary in 33% (3/9). The return vessel was external jugular in 78% (7/9) and internal jugular in 22% (2/9). Two overlapping Viabahn stent grafts were used in 88% of cases (7/8) and 3 stent grafts in 1 case. In the initial case, 2 Gore hybrid grafts were used. Stent graft diameter ranged from 9 mm to 13 mm. Mean follow-up was 852 ± 339 days (range, 488-1483 days). At 12 months and 24 months, primary patency was 67% and 67%, and secondary patency was 89% and 78%, respectively. Complications included late thrombosis and secondary infection. There were no anastomotic leaks or seromas associated with extravascular stent grafts. The percutaneous costoclavicular bypass is a feasible option for thoracic outlet and cephalic arch occlusion in symptomatic dialysis patients.

Thrombosed native hemodialysis fistulas: Technical and clinical outcomes of endovascular recanalization and factors influencing patency.

To evaluate the technical and clinical results of endovascular recanalization of thrombosed native hemodialysis fistula and the factors influencing patency. A retrospective study was conducted with 73 patients who had thrombosed arteriovenous fistulas and were treated with endovascular methods. Patient characteristics, arteriovenous fistula-related characteristics, and endovascular procedures were analyzed. Technical and clinical results and patency rates were evaluated. The factors influencing patency were analyzed using a univariate and multivariate Cox proportional hazards model. Technical and clinical success rates were 93% (68/73) and 85% (62/73), respectively. At 3, 6, and 12 months, the primary patency rates were 87.9%, 73.3%, and 64.8%; assisted primary patency rates were 89.2%, 78.6%, and 70.7%; and secondary patency rates were 90.8%, 87.2%, and 83.1%, respectively. Previous intervention and cephalic arch stenosis were risk factors for lower primary and assisted primary patency (p < 0.05 for all). Cephalic arch stenosis was the only risk factor for lower secondary patency (p < 0.05). No major complications associated with the procedures were noticed. Endovascular treatment was effective for the immediate recanalization of thrombosed arteriovenous fistula. In addition, previous intervention and cephalic arch stenosis were significantly related to lower arteriovenous fistula patency.

Biomimetic Stent and Drug Eluting Balloon to Treat Recurrent Cephalic Arch Stenosis

Biomimetic Stent and Drug Eluting Balloon to Treat Recurrent Cephalic Arch Stenosis

Abstract No. 477 Endovascular arteriovenous dialysis fistula intervention: outcomes and factors contributing to fistula failure

To determine post-intervention patency rates and contributing factors for fistula failure in pre-dialysis patients with arteriovenous (AV) dialysis fistulas. Institutional review board approval was obtained for this single-institution retrospective study. All pre-dialysis patients who underwent upper extremity AV fistula creation for anticipated dialysis between October 1995 and January 2015 and who required subsequent endovascular therapy to maintain patency were reviewed. A total of 210 patients were identified. The medical record was queried for patient demographics, procedural details and outcomes. Multiple AV fistula configurations were reviewed: 138 brachiocephalic, 39 radiocephalic, 30 brachiobasilic, 2 ulnocephalic and 1 radiobasilic. Median post-intervention primary patency was 2.7 years, median post-intervention primary-assisted patency was 3.2 years, and median post-intervention secondary patency was 3.6 years. There were 293 initial stenosis treated. This included 5 stenosis in the inflow artery, 50 at the anastomosis, 71 in the juxta-anastomotic segment, 71 in the cannulation zone of the outflow vein, 16 in the noncannulation zone, 10 at the swing point of basilic vein transpositions, 57 in the cephalic arch, and 13 in the central veins. Stenoses in the non-cannulation zone of the outflow vein had the highest rate of target lesion revascularization (TLR) (76.7%), whereas central venous stenosis had the lowest rate of TLR (7.7%). The radiocephalic fistula configuration had better post-intervention primary patency (hazard ratio [HR] 0.58; 95% confidence interval [CI] 0.35-0.96; p=0.034). Conversely, brachiocephalic fistulas had higher risk for loss of post-intervention primary patency (HR 1.90; 95% CI 1.13-3.20; p=0.015). Among predialysis patients who undergo initial endovascular therapy to maintain patency of the AV fistula, the radiocephalic configuration was found to have the best post-intervention primary patency compared to other configurations. While the majority of hemodynamically significant lesions occurred at the anastomosis, lesions in the non-cannulation zone of the outflow vein had the highest rates of TLR.

Using CorMatrix for partial and complete (re)construction of arteriovenous fistulas in haemodialysis patients: (Re)construction of arteriovenous fistulas with CorMatrix.

CorMatrix is an acellular extracellular matrix that acts as a biological scaffold and remodels into site-specific tissue. We used it for the (re)construction of arteriovenous fistulas. In this prospective pilot case study, we used CorMatrix in six patients. We included patients who required vascular access reconstruction due to thrombosis of unsalvageable arteriovenous fistulas, patients with high-flow arteriovenous fistulas and patients with microvasculature in which autologous arteriovenous fistulas did not mature, requiring reconstruction with a graft. We sutured the CorMatrix plate into a tubular shape and then constructed arterial and venous anastomoses. There were no periprocedural complications, CorMatrix-related infections, bleeding or limb swelling after the procedures. CorMatrix was first punctured after 8-10 weeks. In five patients, a percutaneous angioplasty due to CorMatrix stenosis was performed; in one patient, a stent was placed due to refractory stenosis. We observed eight thromboses during the observation period (four in one patient). Perianastomotic stenosis of CorMatrix and interdialytic hypotension were the causes of the thrombosis in five patients, cephalic arch stenosis in two patients and thromboembolism to the brachial artery and arteriovenous fistula in one patient. Thrombendarteriectomy was successful in 87.5% of patients, and one patient required arteriovenous fistula reconstruction. After a median observation period of 12.5 (range 4-23) months, all arteriovenous fistulas were patent, with a median brachial artery flow of 1450 (range 700-1700) mL/min. Arteriovenous fistula (re)construction with CorMatrix seems to be feasible and safe, with a relatively high incidence of neointimal hyperplasia, predominantly at venous anastomoses, but additional clinical studies are needed.

Vascular access related complications with ipsilateral upper limb oedema in hemodialysis

Background: Central vein-related obstruction is a growing problem in maintenance hemodialysis (MHD). Prior to central vein temporary access, failure to implement “fistula first policy” is an important contributor for this problem. It interferes with the outcomes in dialysis adding to mechanical vascular perturbations, resulting in limb, facial, and chest wall edema. Keeping them in view, we undertook this study on MHD patients, presented with central vein-related vascular access problems and ipsilateral upper limb edema, with the aim to investigate the vascular anatomical obstructive lesions causing the clinical syndrome and their management. Materials and Methods: This cross-sectional study included 25 patients of end-stage renal disease on MHD who manifested with vascular access dysfunction, presented with ipsilateral upper limb edema, and were the study subjects. All patients were evaluated with thorough clinical, laboratory, and computed tomographic (CT) angiography (CTAngio) studies to address the issues. Results: All patients had ipsilateral upper limb edema and 36% of them had in addition facial edema. Fifty percent had difficult cannulation with raising venous pressure during HD sessions and difficulty in securing hemostasis at the end of dialysis. CTAngio revealed central vein stenosis in 48%, peripheral stenosis in 20%, and combined central and peripheral stenosis in 32% patients. Cephalic arch involvement was noted in 16% patients. Depending on the patients preference, dialysis switched over to peritoneal dialysis in 24%, new vascular access was created in 20%, and balloon angioplasty in 16% during management. Conclusions: This study describes the central venous-related problems in MHD patients. We reiterate the importance of three early warning signs: high venous pressure, difficulty to achieve hemostasis at the end of dialysis, and ipsilateral limb, face, chest wall edema as the presage signs to suspect and exclude the underlying central vein obstructions. A continuum of management is discussed.

Cephalic arch stenosis masquerading as carotid jugular arteriovenous fistula with a thrill in the neck

Cephalic arch stenosis masquerading as carotid jugular arteriovenous fistula with a thrill in the neck

Endovascular treatment of cephalic arch stenosis in brachiocephalic arteriovenous fistulas: A systematic review and meta-analysis.

The aim of this study is to appraise the current literature on the endovascular management options and their outcomes of cephalic arch stenosis in the setting of a failing brachiocephalic fistula for hemodialysis. A systematic search of the literature was performed using PubMed, Embase, and Google Scholar from January 2000 to December 2017 in accordance with the PRISMA guidelines to investigate the outcomes of endovascular management of cephalic arch stenosis. Data from randomized controlled trials and observational studies, published in the English language, were extracted to determine pooled proportion of primary and secondary patency, using a random-effects meta-analysis. Subgroup analyses of stent grafts, bare metal stents, and percutaneous transluminal angioplasty outcomes were performed. Of the 125 total studies, 11 were included for analysis by consensus. Overall, 457 patients were reviewed and analyzed for primary and secondary patency rates at 6 and 12 months post-treatment. There was significantly higher primary patency at both 6 and 12 months in the stent graft group compared to those who received bare metal stents or percutaneous transluminal angioplasty (relative risk = 0.30-0.31, relative risk = 0.34-0.59, respectively; p < 0.01). Higher secondary patency rates were noted in the bare metal stents cohort compared to the percutaneous transluminal angioplasty cohort at 12 months (relative risk = 0.17, 95% confidence interval = 0.07-0.26; p < 0.01). This study demonstrated a significant benefit in using stent grafts in cephalic arch stenosis compared to bare metal stents or percutaneous transluminal angioplasty with higher primary and secondary patency rates.

Fistuloplasty using a radiation-and-time-saving sheathless balloon catheter

Introduction:Sheath placement in dialysis access interventions is traditionally necessary to obtain imaging, guide percutaneous angioplasty, and evaluate results. The aim of this study was to assess the feasibility of performing sheathless Arterio-venous (AV) access interventions using a novel percutaneous angioplasty balloon catheter.Methods:Between May and September 2017, data on all dialysis access interventions using a novel percutaneous angioplasty balloon with a dedicated injection port were collected. All procedures were performed without a sheath. Success was established as no conversion to sheath placement. Demographic data, location of lesion, time to perform procedure, amount of contrast used, radiation exposure, and access complications were recorded. Ultrasound was used to evaluate access site complications.Results:Sheathless interventions were successful in 24 patients with the mean age of 62 years (29–94). There were 5 PTFE grafts and 19 native fistulas. Lesions were located anywhere from the arterial anastomosis to the cephalic arch. The average balloon size was 6 mm (5–7 mm), and the procedure time was 15.8 min (8–45 min). No access site complications were observed.Conclusion:Sheathless intervention is feasible with several potential advantages, including short procedure time, minimal contrast volume, and reduced radiation exposure. Finally, the lower profile at the access site may result in fewer complications.

血管アクセスのCephalic Arch Stenosisに対する上腕尺側皮静脈への血行路変更

血管アクセスのCephalic Arch Stenosisに対する上腕尺側皮静脈への血行路変更

Treatment Strategies for Cephalic Arch Stenosis in Patients with Brachiocephalic Arteriovenous Fistula

Cephalic arch is one of the sites most susceptible to stenosis in brachiocephalic arteriovenous fistula (BCAVF). We performed a retrospective study to identify the incidence of cephalic arch stenosis (CAS) in BCAVF, to compare the patency of percutaneous transluminal balloon angioplasty (PTA) with that of cephalic vein transposition (CVT), and to establish the optimal treatment strategy for CAS. Between January 2011 and June 2016, 462 patients underwent BCAVF creation. CAS was defined as >50% stenosis at the confluence of the cephalic and axillary veins on ultrasonography. Treatment was planned for clinically significant CAS, which was defined as >25% reduction in flow volume compared to previous examination, elevation of venous pressure, delayed puncture site hemostasis, and/or acute thrombotic occlusion. Seventy-seven (16.7%) patients had CAS and 42 of them (54.5%) were treated for clinically significant CAS. PTA was performed in 36 patients (85.7%), and CVT was done in 6 patients (14.3%) as the initial treatment. Nine patients underwent CVT after PTA, resulting in a total of 15 patients treated with CVT. Investigation of the patency of the 36 cases of PTA and 15 cases of CVT revealed that primary-assisted patency rates at 6 and 12months were 68.2% and 57.3% for PTA and 100.0% and 87.5% for CVT, respectively (P=0.038). Secondary patency rates at 6 and 12months were 72.0% and 56.9% for PTA and 100% and 100% for CVT, respectively (P=0.010). The median intervention rate was 2.5 interventions per access-year in the 36 cases treated with PTA and 1.5 interventions per access-year in the 15 cases treated with CVT. CAS is a common cause of BCAVF dysfunction, and careful surveillance is warranted. CVT should be considered for treatment of CAS to achieve better long-term patency with fewer reinterventions.

Predictive factors of recurrent endovascular intervention for cephalic arch stenosis after percutaneous transluminal angioplasty

ObjectiveCephalic arch stenosis (CAS) is an important and recurring problem arising in hemodialysis patients because of the requirement for repeated interventions to maintain patency. The aim of this study was to determine predictive factors for recurrence of CAS after successful angioplasty. MethodsA retrospective, case-control study was conducted at two ambulatory vascular access (VA) centers. All patients with a dysfunctional VA referred for an angiographic procedure and with a documented CAS as evidenced during the endovascular intervention (EI) between January 1, 2013, and December 31, 2015, were enrolled; 15 patients in whom an efficacious intervention was not possible were excluded. The study thus concerned 375 EIs using percutaneous transluminal angioplasty without stent placement on 241 VAs for CAS (9% of all procedures performed) during a 3-year period. Patients were compared regarding the absence (group 1; n = 181) or presence (group 2; n = 60) of recurrent CAS. We defined recurrence as that which occurred within 180 days of the previous successful EI for CAS. Any CAS diagnosed and treated >180 days after a previous one was considered a novel CAS and not a recurrence. Multivariate analysis was performed to determine variables independently associated with recurrence of CAS. Kaplan-Meier analysis was performed for determination of primary and assisted primary patency in this population. ResultsThe recurrence rate of CAS was high (25%). Patients in both groups had similar demographic characteristics, time on hemodialysis, and mean dialysis dose and access flow rate at referral (P > .05). Multivariate analysis provided a significant discriminatory influence pertaining to diabetes (hazard ratio [HR], 2.054; 95% confidence interval [CI], 1.22-3.46; P = .007), residual stenosis even though it was <30% (HR, 1.86; 95% CI, 1.005-3.439; P = .048), and the finding of an isolated CAS lesion (HR, 0.445; 95% CI, 0.219-0.905; P = .025) in comparing group 1 and group 2. All other variables lost statistical significance on multivariate analysis. Primary patency at 6 months was 72%, increasing to an assisted primary patency of 89% at 6 months. The median durations of primary patency and assisted primary patency were 9.5 months and 15.6 months, respectively. ConclusionsMultivariate analysis showed that diabetes and residual stenosis (albeit <30%) were predictive of recurrence, whereas the finding of an isolated CAS lesion as opposed to stenoses in multiple locations was shown to be negatively associated with recurrent CAS, appearing to be “protective”.

Cephalic vein transposition is a durable approach to managing cephalic arch stenosis.

The proximal cephalic vein that enters the axillary vein (cephalic arch) is a common site of stenosis in patients with upper extremity arteriovenous fistulas for hemodialysis (HD). In this study, we present the outcomes of a series of cephalic vein transposition, to determine its utility in the setting of refractory arch stenosis. We conducted a retrospective review of patients undergoing cephalic vein transposition to manage refractory cephalic arch stenosis from January 1, 2008 to August 31, 2015. Demographics, past medical history, access history of the patients as well as procedural details of the surgery to the stenotic segment, patency of the access, and the need for subsequent interventions were recorded. Twenty-three patients underwent a cephalic vein transposition during the study period. The patients undergoing cephalic transposition had their current access for an average of 3.0 ± 2.6 years and had an average of 2.3 ± 0.9 interventions on the access prior to the surgery. Complications from the surgery were uncommon (8.7%) and no patient required a temporary tunneled dialysis catheter. The re-intervention rate was 0.2 ± 0.2 interventions per patient per year. At two years, primary patency was 70.9% and cumulative patency was 94.7% for the patients with cephalic transposition. Cephalic vein transposition is safe and effective treatment for cephalic arch stenosis without interrupting utilization of the access. The surgical approach to stenosis of the proximal cephalic vein is effective, requires minimal re-interventions, and should be considered for isolated, refractory cephalic arch stenosis in mature arteriovenous fistulas.

Cephalic Arch Stenosis: Location of Stenosis in Indian Hemodialysis Patients.

The cephalic vein is formed over the “anatomical snuff box” and joins the axillary vein just below the clavicular level. The definition of cephalic arch is varied. In the radiology literature, it is defined as the central perpendicular portion of the cephalic vein as it traverses the deltopectoral groove and joins the axillary vein. The possible etiologies of cephalic arch stenosis are numerous. This study aimed to identify patients with cephalic arch stenosis and to discern the domain site of stenosis. This is a retrospective case series of patients who had an arteriovenous fistula with dysfunction of access and ipsilateral upper-limb edema. The clinical features of the access dysfunction were strong pulse due to increased pressure, weak thrill due to poor proximal flow, high static pressure, or decreased dialysis efficiency. All these 25 patients underwent computed tomography (CT) angiogram. The CT angiographic findings revealed cephalic arch stenosis and stenosis in 13 patients (52%). domain IV was slightly more affected than other domains of cephalic arch.

Angioplasty-Induced Cephalic Arch Rupture

Angioplasty-Induced Cephalic Arch Rupture

Use of the Viabahn stent graft for the treatment of recurrent cephalic arch stenosis in hemodialysis accesses

ObjectiveCephalic arch stenosis (CAS) is a frequent and challenging failure mode of brachiocephalic fistulas. Natural tortuosity of the cephalic arch requires special consideration in selecting a treatment modality. Typical percutaneous angioplasty and bare-metal stent (BMS) treatments provide a short-term treatment solution for CAS without a durable effect. This study assessed Viabahn (W. L. Gore & Associates, Flagstaff, Ariz) stent grafts (SGs) as a first-line percutaneous option to provide a durable treatment for CAS. MethodsSG data were collected at a free-standing physician office between July 10, 2009, and January 26, 2011. A single-arm, prospective, observational study was conducted of 50 consecutive CAS patients treated with angioplasty followed by deployment of Viabahn SGs. Outcomes included target lesion primary patency and reintervention rates as well as secondary access patency. Results were compared with historic cohorts of percutaneous balloon angioplasty (N = 50) and angioplasty followed by BMS deployment (N = 50). The cohorts were treated between May 5, 2005, and May 20, 2010, and assessed in chronologic order. ResultsThe SG cohort target lesion primary patency reported at 3, 6, and 12 months was 90% ± 7%, 74% ± 12%, and 60% ± 14% (±95% confidence interval), respectively. Compared with historic cohorts, the SG cohort demonstrated statistically superior target lesion primary patency (P < .001), with a reduced reintervention rate per access-year (P < .001). Secondary access patency was statistically superior compared with the percutaneous balloon angioplasty cohort (P = .034) but not statistically different from the BMS cohort when assessed during a 2.5-year period. The secondary access patency for the SG cohort at 5 years was 80% ± 15%. ConclusionsIn treatment of a CAS, the Viabahn SG study group demonstrated superior target lesion primary patency and required fewer subsequent interventions compared with historic cohorts treated with angioplasty or angioplasty followed by BMS placement. Given the significant improvement in target lesion primary patency, future studies should challenge Viabahn SGs as a primary percutaneous treatment modality vs durable surgical alternatives.