ABSTRACT
OBJECTIVES: To evaluate the efficacy of advanced stent technology in the management of failing arteriovenous grafts (AVGs). BACKGROUND: End-stage renal disease rates and the need for hemodialysis are increasing worldwide. AVG remains a common dialysis access site. Several techniques have been previously suggested to restore and preserve AVG patency. A quantitative evaluation and synthesis of this information are essential in elucidating the role of newer stent platforms for the management of failing AVG. METHODS: We performed a literature search using PubMed, Web of Science, and Embase from January 2006 to December 2017. Studies comparing the primary patency rates with stent placement vs balloon angioplasty alone in patients with failed AVGs were included. RESULTS: Seven studies with a total of 1109 patients met the inclusion criteria. The mean graft age was 2.89 years in the stent group and 3.29 years in the balloon angioplasty group. Stent placement was associated with improved primary patency rates compared with balloon angioplasty alone at short-term (3-month) follow-up (73.2% vs 42.6%, respectively; risk ratio [RR], 0.55; 95% confidence interval [CI], 0.35-0.88; P=.01) and mid-term (6-month) follow-up (50.8% vs 18.4%, respectively; RR, 0.65; 95% CI, 0.51-0.82; P<.001). The primary patency rates remained favorable with stent placement at 12-month (40.3% vs 13.0%, respectively; RR, 0.69; 95% CI, 0.63-0.77; P<.001) and 24-month follow-up (20.5% vs 6.8%; RR, 0.86; 95% CI, 0.80-0.92; P<.001) compared with balloon angioplasty alone. CONCLUSIONS: Stent placement is associated with improved patency rates compared with balloon angioplasty alone.
Subject(s)
Angioplasty, Balloon/methods , Arteriovenous Shunt, Surgical/adverse effects , Graft Occlusion, Vascular/surgery , Prosthesis Implantation , Arteriovenous Shunt, Surgical/methods , Comparative Effectiveness Research , Humans , Kidney Failure, Chronic/therapy , Prosthesis Implantation/instrumentation , Prosthesis Implantation/methods , Renal Dialysis/methods , Stents , Vascular PatencyABSTRACT
The MitraClip system can be used to control regurgitant blood flow in patients with mitral regurgitation who cannot tolerate open surgery to replace the mitral valve. Technical limitations make the right femoral vein the standard access point for placing the MitraClip. However, this route is not always suitable. We present the case of an 85-year-old woman in whom we successfully used a left-sided approach for inserting a MitraClip because her right femoral vein was occluded. This apparently novel left femoral approach merits consideration as an option for device insertion when right femoral vein access is precluded.
Subject(s)
Cardiac Catheterization/methods , Heart Valve Prosthesis , Mitral Valve Insufficiency/surgery , Mitral Valve/surgery , Aged, 80 and over , Echocardiography , Female , Femoral Vein , Fluoroscopy , Heart Valve Prosthesis Implantation , Humans , Mitral Valve/diagnostic imaging , Mitral Valve Insufficiency/diagnosis , Treatment OutcomeABSTRACT
BACKGROUND: Endovascular approach to superficial femoral artery (SFA) disease, the most common cause of symptomatic peripheral arterial disease, remains fraught with high failure rates. Newer devices including second-generation nitinol stents, drug-coated stents, drug-coated balloons, covered stents, cryo-therapy, LASER, and directional atherectomy have shown promising results. Clinical equipoise still persists regarding the optimal selection of devices, largely attributable to the different inclusion criteria, study population, length of lesions treated, definition of "patency" and "restenosis," and follow-up methods in the pivotal trials. METHODS: A prospective protocol was developed. We performed a literature search using PubMed from January 2006 to November 2013. Published articles including endovascular interventions in SFA or popliteal arteries with reported 12-month "primary patency" or "binary restenosis" rates as endpoints were included. RESULTS: We identified 6,024 patients in 61 trials reporting 12-month primary patency rates in patients with femoropoliteal disease. Primary patency rates were (weighted average) 77.2% for nitinol stents, 68.8% for covered stents, 84% for drug eluting stents, 78.2% for drug eluting/coated balloon, 60.7% for cryoballoon, 51.1% for LASER atherectomy, 63.5% for directional atherectomy and 70.2% with a combination of endovascular devices. CONCLUSION: The most frequently used endovascular devices yielded various 12-month primary patency rates ranging from 51% to 85%. The increased variation in inclusion criteria, length, and complexity of lesions between studies does not allow direct comparison between them. Larger randomized trials in specific patient populations comparing those modalities is needed before we can make safe recommendation of the superiority of one device over the other.
