Rejoining Veins for Forced Maturation of Small-Caliber Arteriovenous Fistula.

BACKGROUND: To evaluate the efficacy of rejoining mainstream and accessory veins for forced maturation of autogenous arteriovenous fistula (AVF). METHODS: Twenty-three patients who underwent forced maturation through vein rejoining between January 2018 and September 2022 were included. In cases where AVF maturation failure due to the presence of accessory veins, rejoining was primarily considered when distinguishing the main branch becomes challenging. This difficulty typically occurs when the sizes of the 2 vessels are nearly equal and the combined diameters of these veins exceed 6 mm. RESULTS: The mean age and follow-up duration were 57.39 ± 16.22 years and 965.65 ± 573.42 days, respectively. Rejoining of both arterial and venous cannulation sites was performed in 11 patients (47.8%), and rejoining of only the venous cannulation site or only the arterial cannulation site was performed in 11 patients (47.8%) and 1 patient (4.3%), respectively. The mean vein size was 0.35 ± 0.06 cm before rejoining and 0.69 ± 0.07 cm after surgery, indicating a significant increase in size (P < 0.01), whereas the flow did not change significantly following rejoining surgery. Maturation and cannulation success was 100%. The 1-year primary patency rate after surgery was 82.0%. During the follow-up period, 34.8% of the patients required additional percutaneous transluminal angioplasty to maintain patency, and 2 patients (11.8%) had stenosis in the rejoined section. CONCLUSIONS: Rejoining surgery is an effective method for achieving AVF maturation in patients with accessory veins when identification of the mainstream vein is difficult, and this method may be considered when achieving maturation by sacrificing 1 vein is expected to be challenging.

Comparison of pharmacological thrombolysis with mechanical thrombectomy in thrombosed arteriovenous fistulas and grafts: a systemic review and meta-analysis.

AIM: To compare the effectiveness and safety of pharmacological thrombolysis and mechanical thrombectomy. MATERIAL AND METHODS: This review was conducted in accordance with the PRISMA guidelines. Pooled proportions and subgroup analysis were calculated for primary and secondary patency rates, technical success, clinical success, major and minor complications rates. RESULTS: This systematic review identified a total of 6,492 studies of which 17 studies were included for analysis. A total of 1,089 patients comprising 451 (41.4 %) and 638 (58.6 %) patients who underwent thrombolysis and mechanical thrombectomy procedures, respectively, were analysed. No significant differences were observed between thrombolysis and mechanical thrombectomy procedures in terms of technical success, clinical success, major and minor complications rates, primary and secondary patency rates; however, subgroup analysis of overall arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) demonstrated a significantly higher rate of major complications within the AVF group (p=0.0248). CONCLUSION: The present meta-analysis suggests that pharmacological thrombolysis and mechanical thrombectomy procedures are similarly effective and safe; however, AVFs are subject to higher major complications compared to AVGs.

Two-Year Cumulative and Functional Patency after Creation of Endovascular Arteriovenous Hemodialysis Fistulae.

PURPOSE: To assess 2-year cumulative and functional patency of endovascular arteriovenous fistulae (endoAVF) created with the WavelinQ device. MATERIALS AND METHODS: Patients who had fistulae created at a single center from December 2019 to December 2020 were included in this retrospective study. Forty-three patients underwent endoAVF creation (22 females, 21 males). Data collected included patient demographics, location of fistula creation, interventions performed, and brachial artery flow before and after creation. Two-year cumulative and functional patency rates were assessed with Kaplan-Meier method, and variables that affected patency and maturation were examined using Cox proportional hazards model. RESULTS: Technical success was 95% (41/43), and in 4 patients, the fistula did not mature for dialysis use (9.7%). For the remaining 37 patients with endoAVF maturation, 25 had ulnar-ulnar fistulae, 10 had radial-radial fistulae, and 2 had interosseous artery-vein fistulae. Mean maturity time was 73 days, and brachial artery flow of >886 mL/min was predictive of maturation. Mean tunneled dialysis catheter removal time was 133 days. Number of interventions per patient-year was 0.38, where 8 were maturation procedures (5 vein elevations/transpositions and 3 coil embolizations) and 21 were maintenance angioplasties. Two-year cumulative/secondary and functional patency rates were 89.4% and 92.1%, respectively, with a mean follow-up of 665.7 days. Examined variables did not impact cumulative or functional patency. One adverse event was migration of coil to the heart, which was successfully retrieved at time of procedure. CONCLUSIONS: Two-year patency of 89.4% and functional patency of 92.1% were observed after endoAVF creation with WavelinQ device.

A Cost-Effective Approach to Resistant AV Fistula Stenosis: Successful Treatment Using Coronary OPN NC® Balloon in a Low-Income Setting.

Stenosis in the anastomotic site or venous limb of an arteriovenous fistula (AVF) is the most frequent cause of AVF failure. Percutaneous angioplasty with a standard or high-pressure balloon is the first-line treatment for AVF stenosis due to its higher technical success rate (90%) and lower complication rate (4%). Almost 20% of stenosis cases are resistant or undilatable by regular-pressure balloon angioplasty due to fibrosis, leading to technical failure or restenosis. Alternative therapies, such as atherectomy devices or cutting balloons, are expensive and difficult to obtain in low-income developing countries. We successfully treated resistant AVF stenosis with a coronary OPN-NC® ultra-high-pressure balloon and produced a good angiographic result with technical success. Coronary hardware is easily available and relatively cheaper compared to dedicated peripheral balloons or devices in our country due to reuse, which can be a boon in such type of cases. According to the standard hospital protocol, Cathlab hardware was reused.

Efficacy of cutting balloon angioplasty versus high-pressure balloon angioplasty for the treatment of arteriovenous fistula stenoses in patients undergoing hemodialysis: Systematic review and meta-analysis.

This systematic review and meta-analysis aimed to assess and compare the therapeutic outcomes of cutting balloon angioplasty and high-pressure balloon angioplasty for arteriovenous fistula stenosis in hemodialysis patients. All studies indexed in PubMed, Embase, and Cochrane Library Web of Science were retrieved. The retrieval deadline was July 15, 2023. Risk of bias 2.0 was used to evaluate the quality of the included studies. Revman 5.4 software was used for data analysis. This review included three studies and 180 patients, with 90 patients in the cutting balloon angioplasty group and 90 patients in the high-pressure balloon angioplasty group. The results of the meta-analysis suggested that compared with high-pressure balloon angioplasty, cutting balloon angioplasty can improve primary lesion patency rates of internal arteriovenous fistulas at 6 months (relative risk, 1.45; 95% confidence interval, 1.08-1.96; P = 0.01). However, there were no significant differences between the technical success rate (relative risk, 0.99; 95% confidence interval, 0.93-1.05; P = 0.72) and clinical success rate (relative risk, 1.01; 95% confidence interval, 0.95-1.07; P = 0.73). Therefore, cutting balloon angioplasty is likely to increase primary lesion patency rates at 6 months. However, more high-quality, large-sample, multicenter, randomized controlled trials are needed for further validation due to the limited number of included studies.

Treatment of Hemodialysis Vascular Access Repeated Stenosis with Paclitaxel-Coated Balloon Angioplasty: A Retrospective Study.

INTRODUCTION: The objective of this study was to report our experience of angioplasty with paclitaxel-coated balloon (PCB) versus common balloon (CB) for the treatment of repeated failing vascular access. METHODS: Retrospective, single-center analysis consisting of 88 patients treated with percutaneous transluminal angioplasty in the period from October 2020 through December 2021. Patients were divided into two groups according to the type of treatment as PCB (n = 41) and CB (n = 47). We analyzed target lesion primary patency and vascular access primary patency for 6 months and the rate of complications. RESULTS: There was no significant difference in the target lesion primary patency which was similar for 6 months between the two groups (PCB group vs. CB group at 1, 3, and 6 months; 95.12 vs. 89.36% (p = 0.55), 75.61 versus 74.47% (p = 0.90), 53.66% versus 63.83% (p = 0.33), respectively). Similarly, vascular access primary patency in the PCB group and CB group was 90.24 and 89.36% (p = 0.83), respectively, at 1 month, 65.85 and 68.09% (p = 0.82), respectively, at 3 months, 39.02 and 53.19% (p = 0.18), respectively, at 6 months. There were no major complications after endovascular treatment. CONCLUSION: Compared to CB angioplasty, PCB angioplasty has no short-term patency benefit in the treatment of vascular access repeated stenosis.

A Prospective Multicenter Randomized Controlled Trial for Comparing Drug-Coated and Conventional Balloon Angioplasty in Venous Anastomotic Stenosis of Hemodialysis Arteriovenous Grafts.

PURPOSE: To evaluate the efficacy and safety of drug-coated balloon angioplasty compared to conventional balloon angioplasty in the treatment of dysfunctional arteriovenous grafts. MATERIALS AND METHODS: This prospective, multicenter, randomized clinical trial enrolled 190 patients with venous anastomotic stenosis in arteriovenous grafts at five participating hospitals. During pre-dilation, 4 patients dropped out due to ruptures requiring further treatment (n = 2) and residual stenosis of > 30% (n = 2). On successful pre-dilation with a 7 mm conventional balloon, patients were randomized to undergo either a 7 mm drug-coated balloon (n = 94) or conventional balloon angioplasty (n = 92). The primary out-come measure was target lesion primary patency at 3 and 6 months. The secondary out-come measures included target lesion primary patency at 12 months and access circuit primary patency at 6 and 12 months, clinical and technical success rates, and 12-month mortality differences between the groups. RESULTS: The target lesion primary patency and access circuit patency rates at 3 and 6 months were significantly higher in drug-coated balloon angioplasty group as compared to conventional balloon angioplasty group. The technical and clinical success rates were 100% for both the groups. As a procedure-related complication, anastomotic site rupture occurred during pre-dilation in 4 cases. The number of deaths during the 12-month follow-up was one for each group. The number of early thrombotic events (at < 3 months) was significantly higher in the drug-coated balloon group (p = 0.002). CONCLUSION: Drug-coated balloon angioplasty was more effective and safer for the treatment of dysfunctional arteriovenous grafts compared to conventional balloon angioplasty.

Patency and Durability of Stent Grafts Placed in the Dialysis Circuit Cannulation Zone.

PURPOSE: To investigate the safety, durability, and patency rates of stent grafts (SGs) placed in the cannulation zone of hemodialysis access circuits. MATERIALS AND METHODS: From April 2020 to April 2023, all procedures with SGs placed in the cannulation zone were retrospectively analyzed. A total of 40 patients (25 men and 15 women) with SGs placed in the cannulation zone were included in the study. Mean age of the patients was 70 years. The Covera covered stent (BD, Franklin Lakes, New Jersey) was used in all cases. Of these, 26 were arteriovenous (AV) fistulae and 14 were AV grafts. SGs were placed for residual stenosis, perforation, aneurysm, and thrombosis. Follow-up outcomes were determined using follow-up angiographic images and included primary patency, primary-assisted patency, and secondary patency. RESULTS: The primary patency of the target lesion was 89% (SD ± 5) and 74% (SD ± 8.4) at 6 and 12 months, respectively. The primary-assisted patency was 89% (SD ± 5.2) and 78% (SD ± 7.6) at 6 and 12 months, respectively. Secondary patency of the access circuit was 97% (SD ± 2.5) at both 6 and 12 months. Mean follow-up was 332 days (range, 28-661 days). All SGs were successfully cannulated for hemodialysis. No cases of stent fracture or stent infection were observed during follow-up. CONCLUSIONS: SGs placed for cannulation zone pathologies can be safely cannulated for dialysis and have adequate short- and mid-term patency rates.

Association between heart failure and arteriovenous access patency in patients with end-stage renal disease on hemodialysis.

BACKGROUND: Heart disease and chronic kidney disease are often comorbid conditions owing to shared risk factors, including diabetes and hypertension. However, the effect of congestive heart failure (CHF) on arteriovenous fistula (AVF) and AV graft (AVG) patency rates is poorly understood. We hypothesize preexisting HF may diminish blood flow to the developing AVF and worsen patency. METHODS: We conducted a single-institution retrospective review of 412 patients with end-stage renal disease who underwent hemodialysis access creation from 2015 to 2021. Patients were stratified based on presence of preexisting CHF, defined as clinical symptoms plus evidence of reduced left ventricular ejection fraction (EF) (<50%) or diastolic dysfunction on preoperative echocardiography. Baseline demographics, preoperative measures of cardiac function, and dialysis access-related surgical history were collected. Kaplan-Meier time-to-event analyses were performed for primary patency, primary-assisted patency, and secondary patency using standard definitions for patency from the literature. We assessed differences in patency for patients with CHF vs patients without CHF, patients with a reduced vs a normal EF, and AVG vs AVF in patients with CHF. RESULTS: We included 204 patients (50%) with preexisting CHF with confirmatory echocardiography. Patients with CHF were more likely to be male and have comorbidities including, diabetes, chronic obstructive pulmonary disease, hypertension, and a history of cerebrovascular accident. The groups were not significantly different in terms of prior fistula history (P = .99), body mass index (P = .74), or type of hemodialysis access created (P = .54). There was no statistically significant difference in primary patency, primary-assisted patency, or secondary patency over time in the CHF vs non-CHF group (log-rank P > .05 for all three patency measures). When stratified by preoperative left ventricular EF, patients with an EF of <50% had lower primary (38% vs 51% at 1 year), primary-assisted (76% vs 82% at 1 year), and secondary patency (86% vs 93% at 1 year) rates than those with a normal EF. Difference reached significance for secondary patency only (log-rank P = .029). AVG patency was compared against AVF patency within the CHF subgroup, with significantly lower primary-assisted (39% vs 87% at 1 year) and secondary (62% vs 95%) patency rates for AVG (P < .0001 for both). CONCLUSIONS: In this 7-year experience of hemodialysis access creation, reduced EF is associated with lower secondary patency. Preoperative CHF (including HF with reduced EF and HF with preserved EF together) is not associated with significant differences in overall hemodialysis access patency rates over time, but patients with CHF who receive AVG have markedly worse patency than those who receive AVF. For patients with end-stage renal disease and CHF, the risks and benefits must be carefully weighed, particularly for those with low EF or lack of a suitable vein for fistula creation.

The efficacy of percutaneous transluminal angioplasty and arteriovenous fistula reconstruction for immature arteriovenous fistula.

BACKGROUND: To access the efficacy of percutaneous transluminal angioplasty and arteriovenous fistula reconstruction for immature arteriovenous fistula, compare the long-term patency and post-operative complications between them. MATERIALS AND METHODS: The medical records and Hemodialysis record sheets from 44 patients between May 2020 and January 2022 who underwent percutaneous transluminal angioplasty or arteriovenous fistula reconstruction treatment for immature autogenous arteriovenous fistula (AVF) were retrospectively reviewed. The patients were divided into two groups according to the type of surgery they received, including 25 patients in the PTA group and 19 patients in the AVF reconstruction group. Clinical outcomes were included, such as the primary and secondary patency rates following the procedure, maturation time, peak systolic velocity (PSV) of brachial artery, maximum pump-controlled blood flow at initial dialysis, and post-operative complications rates in the two groups. RESULTS: Technical and clinical success was achieved in 100% of the 44 cases. For patients who underwent percutaneous transluminal angioplasty, the primary patency rate at 3, 6, and 9 months was 84.0%, 68.0%, 60.0%, and the secondary patency rate was 92.0%, 84.0%, 80.0%, respectively. And for patients who underwent arteriovenous fistula reconstruction, the primary patency rate at 3, 6, and 9 months was 89.5%, 73.7%, 68.4%, and the secondary patency rate was 100.0%, 94.7%, 94.7%, respectively. There were no significant differences between the two groups in terms of patency rates (p > .050). In patients whose maturation was successful, the average maturation time of fistula after the PTA procedure was 19.36 ± 13.94 days, and 58.63 ± 18.95 days for the reconstruction procedure (p < .010). The PSV of brachial artery before and after the procedure was 87.64 ± 23.87 cm/s and 153.20 ± 21.69 cm/s in PTA group, for reconstruction group, the number was 86.26 ± 20.59 cm/s and 151.26 ± 29.94 cm/s, respectively. No statistically significant differences (p > .050). The maximum pump-controlled blood flow at initial dialysis was 232.60 ± 16.72 ml/min in PTA group, which was significantly higher than 197.11 ± 10.45 ml/min in reconstruction group (p < .010). Subcutaneous hematoma, restenosis, thrombus formation, and pseudoaneurysm were major complications in PTA group. Restenosis, thrombus formation, and pseudoaneurysm were major complications in reconstruction group, with no statistically significant differences between the two groups (p > .050). CONCLUSION: When immature AVFs require reconstruction surgery, the patency outcomes are comparable to AVFs that undergo successful management by PTA. While, when AVFs are successfully managed by PTA, they have significantly less maturation times and higher maximum pump-controlled blood flow rates at initial dialysis AVF use.

Maintenance and Salvage of Hemodialysis Access.

Many end-stage kidney failure patients require hemodialysis as a life-sustaining treatment. Hemodialysis access via arteriovenous fistula or graft creation is preferred over long-term dialysis catheters, but intervention to maintain patency and prevent access failure is common. Endovascular and open surgical techniques are both utilized to address the underlying etiology of failure. Endovascular options include balloon angioplasty, angioplasty with stenting, and drug-eluting stents. Open revision is commonly needed for recurrent stenosis, aneurysmal or pseudoaneurysmal change, hemodialysis access-induced distal ischemia, and infection. Treatment plans should be guided by patient's individualized goals of care and require a multidisciplinary approach to the management of this complex disease.

Factors affecting the primary patency of native arteriovenous fistulas after ultrasound-guided percutaneous transluminal angioplasty.

OBJECTIVE: By analyzing the clinical history, laboratory test indexes, and intraoperative ultrasound imaging data of patients receiving ultrasound-guided percutaneous transluminal angioplasty (UG-PTA) for the first time, the application value of UG-PTA in the treatment of peripheral stenosis of autogenous arteriovenous fistula (AVF) and the related factors affecting postoperative patency were investigated. METHODS: A total of 381 patients with dysfunction of radio-cephalic AVF were treated with UG-PTA from June 2017 to September 2019. According to the inclusion and exclusion criteria, 199 patients were included in this study. Baseline characteristics of patients, including demographic, clinical, and laboratory data, were collected. Kaplan-Meier's survival curve was used to demonstrate the cumulative primary patency rate of UG-PTA. Univariate and multivariate Cox regression analysis was performed on clinical, anatomic, biochemical, and medication variables to identify the predictors of postintervention primary patency. RESULTS: The early technical success rate of UG-PTA was 98.4% (375/381). One hundred and ninety-nine patients, with an average age of 52.9 years, were analyzed, 97 of whom were males (48.7%). The median follow-up duration was 21 months. No major complication was observed. Postintervention primary patency rates were 87.7%, 75.8%, and 60.0% at 6, 12, and 24 months, respectively. A previously failed AVF (HR, 1.935, 95% CI 1.071-3.494; p = .029) and an increased level of parathyroid hormone (HR per 100 pg/mL increase, 1.105; 95% CI 1.014-1.203; p = .004) were identified as independent negative predictors of primary patency of UG-PTA. CONCLUSIONS: UG-PTA is a safe and effective method for the treatment of peripheral stenosis of AVF. Previously failed AVF and elevated parathyroid hormone levels are associated with lower primary patency rate.

The Role of Drug-Coated Balloon in Haemodialysis Arteriovenous Fistula Stenosis Management.

Arteriovenous fistula (AVF) stenosis is a common problem leading to dialysis access dysfunction. The conventional balloon (CB) is the most commonly used device during angioplasty but suffers from poor durability of results due to neointimal hyperplasia-mediated recurrence. The drug-coated balloon (DCB) is an adjunct to balloon angioplasty that reduces neointimal hyperplasia, thereby improving post-angioplasty patency. Despite the heterogeneity of DCB clinical trials to date, the evidence suggests that DCBs of different brands are not necessarily equal, and that patient selection, adequate lesion preparation and proper DCB procedural technique are important to realize the benefit of DCB angioplasty.

Comparison of drug-coated balloon angioplasty versus common balloon angioplasty for arteriovenous fistula stenosis: A systematic review and meta-analysis.

Drug-coated balloons (DCBs) have been used in dialysis patients with arteriovenous fistula (AVF) stenosis, but whether DCBs have advantages over ordinary balloons is still controversial. A meta-analysis was designed to investigate the safety and efficacy of DCBs and common balloons (CBs) in the treatment of AVF stenosis. We searched the PubMed, EMBASE, and China National Knowledge Internet (CNKI) databases for randomized controlled trials that evaluated the comparison of DCB angioplasty versus CB angioplasty for AVF stenosis in dialysis patients and reported at least one outcome of interest. The results showed that the DCB group had a higher first-stage patency rate of the target lesion 6 months [odds ratio, OR = 2.31, 95% confidence interval, CI: (1.69, 3.15), p < .01] and 12 months [OR = 2.09, 95% CI: (1.50, 2.91), p < .01] after surgery. There was no statistically significant difference in all-cause mortality between the two groups at 6 months [OR = 0.85, 95% CI: (0.47, 1.52), p = .58] and 12 months [OR = 0.99, 95% CI: (0.60, 1.64), p = .97]. Compared with CB, DCBs as a new endovascular treatment for AVF stenosis have a higher primary patency rate of target lesions and can delay the occurrence of restenosis. There is no evidence that DCB can increase the mortality of patients.

Dialysis Access Maintenance: Plain Balloon Angioplasty.

Plain balloon angioplasty remains the first-line treatment for dialysis access stenosis. This chapter reviews the outcomes of plain balloon angioplasty from cohort studies and comparative studies. Angioplasty outcomes are more favourable in arteriovenous fistulae (AVF) compared to arteriovenous grafts (AVG) with primary patency at 6 months ranging from 42-63% compared to 27-61%, respectively, and improved for forearm fistulae compared with upper arm fistulae. Higher pressures are required to treat stenoses in AVFs compared to AVGs. Outcomes are worse in more severe stenoses, increased patient age, previous interventions and fistulae that develop early stenoses. Major complication rates following angioplasty in dialysis access are between 3 and 5%. Repeat treatments and the use of adjuncts such as drug-coated balloons and stents can prolong the patency of dialysis access. Level of Evidence No level of evidence (Review paper).

Custom-designed sensors embedded 3D-printed wearable device for improving the hemodialysis-related vascular dysfunction detection.

BACKGROUND: The increasing prevalence of end-stage renal disease (ESRD) imposes a substantial economic burden on public health-care systems. Hemodialysis (HD) is a pivotal treatment modality for patients with ESRD. However, prolonged use of HD vessels may result in stenosis, thrombosis, and occlusion due to repeated daily punctures. Thus, early detection and prevention of the dysfunction of dialysis routes are crucial. OBJECTIVE: In this study, we designed a wearable device for the early and accurate detection of arteriovenous access (AVA) stenosis in HD patients. METHODS: A personalized three-dimensional (3D) printed wearable device was designed by combining the phonoangiography (PAG) and photoplethysmography (PPG) techniques. The capability of this device to monitor AVA dysfunction before and after percutaneous transluminal angioplasty (PTA) was evaluated. RESULTS: After PTA, the amplitudes of both PAG and PPG signals increased in patients with arteriovenous fistulas and those with arteriovenous grafts; this might be due to increased blood flow. CONCLUSION: Our designed multi-sensor wearable medical device using PAG, PPG, and 3D printing appears suitable for early and accurate detection of AVA stenosis in HD patients.

Outflow Rescue of Elbow-Blockade Forearm Arteriovenous Fistulas: Outcomes of Open Surgical Techniques.

BACKGROUND: Venous scarring at the elbow is a common problem that can cause early and late forearm arteriovenous fistula (AVF) dysfunction in hemodialysis patients. However, any effort to prolong the long-term patency of distal vascular accesses could benefit the patient's survival, maximizing the use of restricted venous patrimony. This study aims to report a single-center experience in the recovery of distal autologous AVF with venous outflow obstruction at the elbow using different surgical techniques. METHODS: Retrospective observational study of all patients treated at a single vascular access center from January 2011 to March 2022, with dysfunctional forearm AVFs presenting with outflow stenosis or occlusions at the elbow treated by open surgery, using 3 different surgical techniques. Demographics and clinically relevant data were collected. Evaluated endpoints included primary, assisted primary, and secondary patency rates at 1 and 2 years. RESULTS: Twenty-three patients with elbow-blocked outflow forearm AVFs have been treated with a mean age of 64 ± 15 years. The majority (96%) had a radiocephalic fistula. The median time from vascular access creation to intervention was 34.5 months (12-216 months). A total of 24 procedures have been performed using 3 different surgical techniques for bypassing the obstructed venous outflow at the elbow. Technical success was achieved in 96% of the surgically treated patients. Primary and secondary patency rates at 1 year were 67.4% and 89.4%, respectively, and 52.9% and 82.0% at 2 years, with a median follow-up of 19 months (6-92 months). CONCLUSIONS: AVFs outflow stenosis or occlusions at the elbow not amenable to endovascular therapy could lead to vascular access abandonment. Our study demonstrates multiple surgical solutions to avoid this adverse outcome. Elbow venous outflow surgical reconstruction seems effective for distal vascular access preservation. Close surveillance is essential for timely endovascular treatment of newly developed stenosis at the venous drainage.

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

PURPOSE: To assess long-term patency rates of cephalic arch stent grafts in brachiocephalic fistulae and the importance of device position. MATERIALS AND METHODS: This 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. RESULTS: Protrusion 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. CONCLUSIONS: This 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.