Role of percutaneous radiological intervention for treatment of dysfunctional hemodialysis vascular access

ABSTRACT

Early detection and percutaneous treatment of stenosis and thrombosis of hemodialysis access either native fistula [AVF] or graft can prolong the use of these shunts. The study is designed to investigate the role of interventional radiological procedures in treatment of failed hemodialysis access. Between year 2003 and 2006, 19 patients with upper limb shunts were subjected for multiple diagnostic angiographic procedures for their failing hemodialysis access. Detection of thrombosis or stenosis was followed by interval complex treatment. For all patients; 11 thrombolytic therapies, 29 dilations and 5 stent placements were done. These were performed in 13 native fistulas [9 forearms. 4 upper arm] and 6 prosthetic grafts. Restenosis and rethrombosis were treated by consecutive redilation and further declotting. The dysfunction was related to the venous side of hemodialysis access in 90% of patients while it was on the arterial side in only 10%. The initial interventional success rate was 88% in the forearm. 100% in upper arm and 83% in grafts. The complications were mild and transient including 4 hematomas at puncture sites, 4 consequent access infection and 2 arrhythmic episodes; all were managed conservatively. The mean primary patency rates at 1 year period were ranging from 62.5% to 25% [62.5% for forearm AVFs, 25% for upper arm AVFs, and 40% for grafts] [P<0.05]. The secondary patency rates at 1 year were ranging from 88% to 75% [88%forforearm AVFs 75% for upper arm AVFs and 80% for grafts]. Mean period necessary for reintervention was 14 months in the forearm 5 months in the upper arm and 6.5 months in grafts [P<0.05]. All patients are maintained on Aspirin and Coumarin. The percutaneous treatment of stenosis and thrombosis in hemodialysis access was effective in 90% of cases and yielded a mean 40% primary and 80% secondary patency rates at one year period. The overall results were more encouraging in native forearm AVFs compared to upper arm AVFs and grafts where maintenance of the two latters need more interventions: