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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 34  |  Issue : 2  |  Page : 696-702

Percutaneous transluminal angioplasty as a treatment of stenosis of arteriovenous fistula for hemodialysis


1 Department of General and Vascular Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of General and Vascular Surgery, Ahmed Maher Teaching Hospital, Cairo, Egypt

Date of Submission01-Oct-2020
Date of Decision11-Jan-2021
Date of Acceptance18-Jan-2021
Date of Web Publication30-Jun-2021

Correspondence Address:
Hossam M. Adel Ibrahim Eissa
Eissa, MBBCh, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_364_20

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  Abstract 


Objective
The aim of our study is to evaluate the endovascular option for treatment of arteriovenous fistula (AVF) stenosis through assessment of success rates and primary patency rate after the angioplasty procedure.
Background
The quality of life of hemodialysis patients depends mainly on the patency and proper function of their vascular access. The main cause of AVF dysfunction is stenosis of the fistula. Vascular surgeons should have many surgical and endovascular plans to keep the hemodialysis access patent and functioning. Percutaneous transluminal angioplasty has become an established treatment of dysfunctional AVFs, with many advantages and benefits for the patients.
Patients and methods
A prospective study was conducted on 30 patients having end-stage renal disease scheduled for or already on regular hemodialysis with failing or recently failed native AVF during February 2018 till February 2020. Balloon dilation was done alone in 27 cases, whereas it was combined with thrombectomy procedure with a Fogarty catheter in three cases.
Results
A total of 30 patients (19 males and 11 females) were included. Overall, 56.67% of AVFs were brachiocephalic AVF. Radial access was mostly used as an access in 80% of cases, whether percutaneous or surgical. Venous juxta-anastomotic stenosis was the most common site of stenosis (40.91%). Technical success rates in this study reached 86.67%, and the overall primary patency rates were 84.62 and 76.92% at 3 and 6 months, respectively.
Conclusion
Balloon angioplasty of failing or recently failed native AVF is a safe and effective procedure. It is associated with high success rates, low complication rates, and maintained long-term patency of the hemodialysis access.

Keywords: arteriovenous fistula stenosis, balloon angioplasty, hemodialysis, vascular access dysfunction


How to cite this article:
Zaida NA, Abu-Gruidah HS, Ibrahim Eissa HM, Omran WM. Percutaneous transluminal angioplasty as a treatment of stenosis of arteriovenous fistula for hemodialysis. Menoufia Med J 2021;34:696-702

How to cite this URL:
Zaida NA, Abu-Gruidah HS, Ibrahim Eissa HM, Omran WM. Percutaneous transluminal angioplasty as a treatment of stenosis of arteriovenous fistula for hemodialysis. Menoufia Med J [serial online] 2021 [cited 2024 Mar 29];34:696-702. Available from: http://www.mmj.eg.net/text.asp?2021/34/2/696/319725




  Introduction Top


End-stage renal disease (ESRD) is a major problem in both developed and developing countries. It requires one or another modality of the renal replacement therapy. From ~ 640 000 patients in the USA with ESRD, the majority (64.2%) undergo renal replacement therapy via hemodialysis. Less commonly, renal replacement therapy treatments are renal transplant (29.3%) and peritoneal dialysis (6.4%) [1]. Patients on hemodialysis represent the majority of patients and still outnumber those on peritoneal dialysis or transplantation. The creation and maintenance of vascular access for hemodialysis represents the cornerstone in process of hemodialysis [2].

Options of vascular access for hemodialysis include arteriovenous fistula (AVF), AV graft, or catheters. Autogenous AVF, which is defined as an autogenous anastomosis between an artery and a vein, is the preferred modality of access because it has a better long-term patency rates and requires less interventions to maintain patency and also less likely to become infected than synthetic access. Maintaining a healthy patent AVF as long as possible is a big challenge to improve the lifestyle of many patients with ESRD and reducing their suffering [3–5]. It depends on many factors that result in its failure, which may be early (within the first 3 months) or late (after 3 months). These factors may be linked to arterial (inflow) or venous (outflow) causes, and also may be preexisting in the patient or related to operative technical issues and postoperative complications [6].

The chief reason for AVF to become dysfunctional and thrombosed is the development of progressive stenosis owing to neointimal hyperplasia. If there was a reduction greater than 50% of the caliber of the vessel (associated with hemodynamic, functional, or clinical abnormality), the access becomes dysfunctional. Juxta-anastomotic stenosis (lesion in the first 4 cm of the vein) was found to be the most common site of stenosis [7]. Access stenotic lesions were classified according to their location as juxta-anastomotic (type I), in the cannulation segment (type II), and at the outflow into the deep venous system (type III). There are two other types of stenosis not affecting the access itself: central venous lesions caused by longstanding central catheters and stenotic lesions of the arterial inflow [8]. Certain locations for each type of fistula are prone to stenosis. For the radiocephalic fistula, it is mostly the juxta-anastomotic segment; for the brachiocephalic fistula, it is mostly the cephalic arch; and, for the brachiobasilic fistula, it is the mostly proximal swing segment [1],[8].

In the past, failing or recently failed AVF was abandoned completely and a temporary catheter was inserted and a new access was planned. However, owing to the limited number of access sites available for each patient and increasing life expectancy of patients on regular hemodialysis, early detection and treatment of all hemodynamically significant lesions is recommended to prolong the life span of each access as long as possible and to lower the usage of temporary hemodialysis catheters [9].

Balloon angioplasty for failing AVF is an excellent promising treatment option for fistula stenosis and has now replaced surgical therapy as the standard management of vascular access dysfunction, as it has the following advantages: it is more durable than the creation of new access or the catheter placement. This percutaneous intervention is relatively simple, less invasive, enables us to spare other access sites for further use, helps in minimizing the insertion of central catheters, and allows the patient to start dialysis in the day after intervention. Drug-eluting balloons and covered stent grafts have been shown in trials to have fewer rates of reintervention compared with conventional percutaneous transluminal angioplasty (PTA) alone, but when and where should they be used [10]? Here comes the importance of the current study which focused on endovascular management as an option for salvage of dysfunctional AVF for hemodialysis.


  Patients and methods Top


This is a prospective study involving 30 patients having ESRD scheduled for or already on regular hemodialysis with failing or recently failed native AVF. The study was conducted at Menoufia University Hospital and Ahmad Maher Teaching Hospital during the period from February 2017 to October 2019.

Ethical consideration

This study was accepted and approved by ethical committee of Faculty of Medicine, Menoufia University. Written informed consent was obtained from all patients to be included in this study.

Inclusion criteria

The inclusion criteria were patients having dysfunctional native AV access according to one or more of the following criteria as altered (decreased or absent) thrill, increased pulsation, presence of collateral veins, swelling of the limb, difficult cannulation, prolonged bleeding after hemodialysis, high venous pressure on hemodialysis, and low hemodialysis flow rate (total fistula blood flow <500 ml/min) with the ultrasound dilution method.

Exclusion criteria

The exclusion criteria were patients allergic to contrast agents, patients with fistula infection, patients with large aneurismal dilatation with impending rupture judged by skin changes, patients who are persistently hypertensive as in low cardiac output state, and patients who reported previous history of ischemia (steal).

All patients were subjected to history taking including age and sex; presence of comorbidities such as diabetes mellitus, hypertension, and other cardiovascular comorbidities (heart failure, atherosclerosis, etc.); history of present illness (ESRD) as a probable cause of renal failure and duration of hemodialysis; and history of previous access (if present) location and type and current hemodialysis access (location, type, and duration).

Physical examination

It included inspection of the limb with the access to look for old scars, edema, and dilated veins over chest wall or shoulder, indicating occlusion in the central veins; palpation for assessment of arterial pulses of the limb; changes in the pulsation at the area of stenosis: weak or strong pulse; Allen's test to assess contributions of both radial and ulnar arteries to the circulation of the hand; thrill over the area of stenosis with just a systolic element; presence of aneurysm, overlying skin state, and external compression by hematoma; and auscultation as abnormal bruit (high pitched with a systolic component in the area of stenosis).

Doppler/duplex scan was done for all cases. The protocol included assessment of feeding artery from the level of axillary artery, the anastomotic site, draining vein up to the level of subclavian vein, perivascular space to detect presence of any hematoma or seroma outside the lumen, and volume flow, if lower than 600 ml/min indicates a failing AVF. Peak systolic velocity and peak systolic velocity ratio at and before the location of any narrowed areas were assessed. A significant stenosis (≥50% of vein diameter) was suggested if peak systolic velocity was more than or equal to 375 cm/s or peak systolic velocity ratio more than or equal to 3. All procedures took place in the catheterization laboratory under fluoroscopic imaging system under local anesthesia.

Access options included the following: (a) percutaneous radial artery was used in most cases when Allen test was normal. However, open surgical exposure of radial artery was needed when measured less than 2 mm in diameter. (b) Transvenous access (through venous limb of the AVF) was used in case that the venous outflow was patent distal to the anastomosis, especially if there was a limitation to access the radial artery, and (c) transbrachial access was less frequently used [Figure 1].
Figure 1: Different options to gain access: (a) percutaneous radial artery access, (b) open radial artery access, and (c) transbrachial artery access.

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Intervention

After administration of 5000 U of unfractionated heparin, a fistulogram was done to assess the AVF and draining veins and central veins up to the superior vena cava to detect any stenotic lesions. Moreover, introduction of the guide wire was done mostly using a 260 cm 0.035' angled hydrophilic guide wire (Terumo) over a 5 or 4 Fr selective catheter. When the wire crosses the lesion, a 6-mm noncompliant balloon was used (according to the role of sex of fistula maturation); 7 mm balloon can be used in larger veins, and 4–6 mm balloon in cases of juxta-anastomotic lesions. After dilation of the stenotic lesion, fistulogram was done including the central veins to ensure the patency and to exclude any residual stenosis or free floating or flow-limiting thrombi. In case of tight or resistant lesion, we used repeated inflations, higher pressure or shorter balloon, longer inflation duration, or large balloon diameter. In cases of restenosis, the dilatation was repeated using high-pressure balloon. Hybrid procedures were performed in case of markedly filled fistula with thrombi. Thrombectomy procedure of the fistula was done using a Fogarty catheter through a small skin incision and transverse fistulotomy. The sheath was removed and application of manual compression was done, and if access was surgical, the puncture site was closed using interrupted 6/0 prolene sutures.

Outcome measures

Procedure success rates

(a) Angiographic success is the restoration of luminal diameter with acceptable reduction less than 30% [Figure 2]. (b) Technical success is the restoration of a good propagating thrill. (c) Clinical success was the ability to perform three or more successful hemodialysis sessions using pump 300 ml/min via the treated fistula [4],[11].
Figure 2: Successful angioplasty of dysfunctional brachiobasilic AVF, (a) showing anastomotic and juxta-anastomotic lesions. (b) Balloon dilatation of the lesion. (c) Postprocedure imaging showing successful dilatation of the fistula. Regarding successful angioplasty of dysfunctional brachiocephalic AVF via radial artery access; (a) juxta-anastomotic stenosis. (b, c) Dilatation of the lesion with the balloon. (d) Final angiography with good flow inside the fistula. AVF, arteriovenous fistula.

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Primary patency rate

Follow-up for assessment of the patency of the fistula was done through outpatient clinic visits without admission within a time frame of 6 months by means of clinical assessment of thrill, decrease in size of the limb, fading of venous collaterals and other signs of failure, and duplex scan (if required) to evaluate the anatomy, hemodynamic status, and patency of the fistula. Primary patency was considered to start on the day of initial intervention and terminate on the day of failure of the fistula or further reintervention which ever came sooner [4],[12].

Statistical analysis

Results were tabulated and statistically analyzed by using a personal computer using Microsoft Excel 2016 and SPSS v. 21 (SPSS Inc., Chicago, Illinois, USA). Statistical analysis was done using descriptive statistics, for example, percentage (%), mean, and SD.


  Results Top


A total of 30 patients [19 (63.33%) males and 11 (36.67%) females] were involved in the current study. Mean age was 50.33 ± 13 years (range, 25–70 years). Mostly, comorbidities related with the ESRD were hypertension in 11 (36.67%) patients and diabetes mellitus in 10 (33.33%) patients. Five (16.67%) patients had both diseases, whereas four (13.33%) patients were negative for both. The most common clinical presentations for dysfunctional fistula were inefficient dialysis (repeated suction on the dialysis machine and low flow rate), representing 43.33% (13 patients out of 30); abnormal (weak or lost thrill), representing 36.67% (11 patients out of 30); edema of the ipsilateral limb due to venous hypertension (13.33%), mostly caused by previous ipsilateral insertion of central catheter; and prolonged bleeding after the dialysis session, representing 6.67% (two patients out of 30). The incidence of different types of fistulae operated on was distributed as follows: brachiocephalic in 56.67% (17 cases out of 30), brachiobasilic in 23.33% (seven cases out of 30), and radiocephalic in 20% (six cases out of 30). Transradial access was the most common type of access whether percutaneous technique in 70% of cases (21 patients) or open surgical in 10% (three patients), with overall rate of 80%. Transvenous access was done in 16.67% of cases (five patients when there was a limitation to use the radial artery), whereas a transbrachial artery access was done in 3.33% of cases (one patient). In the current study, we found 44 stenotic lesions in the involved 30 cases, as some patients had more than one lesions, leading to fistula dysfunction. The stenotic lesions were anatomically distributed as follows: two (4.55%) arterial stenosis, five (11.36%) anastomotic stenoses, 18 (40.91%) venous juxta-anastomotic stenoses (4 cm from the anastomosis), 12 (27.27%) needling segment stenosis, and seven (15.91%) junctional stenotic lesions (cephalic and basilic arches) [Table 1].
Table 1: Characteristics of the patients and data related to arteriovenous fistula and stenotic lesions

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Moreover, balloon dilation was done alone in 27 cases, whereas it was combined with thrombectomy procedure with a Fogarty catheter in three (10%) cases, that is, two cases before the procedure owing to high thrombus load in a mega vein and one case after the procedure when he had weak thrill after angioplasty with floating thrombi causing flow limitation. The success rates (clinical and radiological) in this study reached 86.67%. Four cases failed to be dilated (13.33%) owing to the following causes: two cases were due to failure to cross the lesion (the two cases had totally occluded lesions at the anastomotic segment), one case had a tight stenotic lesion failed to be dilated by conventional balloons, and the last case had ruptured anastomosis. Complications occurred were minor hematoma of the puncture site that developed in one patient and was managed conservatively. Another one developed ruptured anastomosis and was managed by open surgical ligation of the fistula. The successfully salvaged 26 cases were followed up periodically for duration of 6 months. The overall 1ry patency rates were 84.62 and 76.92% at 3 and 6 months, respectively [Table 2].
Table 2: Percentage of each type of access used in the procedures, success rate, and complications

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  Discussion Top


It is important to determine the patients who would benefit from endovascular management of dysfunctional AVF and exclude patients who will not, and those who will be definitely harmed from the intervention [10]. So, patients having low cardiac output were excluded from the current study as hypotension will cause refailure of the fistula. Moreover, patients with infected fistula or impending rupture of aneurysm were excluded as the proper management of such conditions is to abort the fistula and ligate it, and it is unwise to try to reopen it.

A higher incidence of males over females (63.33 and 36.67%, respectively) was found in our results, with mean age of 50.33 ± 13 years. This is similar to Huijbregts et al. [11], who found male percentage to be 62%, and mean age was 64.6 ± 14.2 years. Moreover, Ghoneim et al.[13] showed that male percentage was 60%, and mean age was 50 ± 12.0 years. In contrast, Nikam et al.[14] declared through their study percentages of 49% males and 51% females, and the mean age was 59 ± 15 years. This is owing to our sample size was less and different inclusion and exclusion criteria.

Regarding the comorbidities, Bakken et al.[15] reported that 76% of cases had hypertension and diabetes mellitus (55%), whereas in 2015, Aktas et al.[16] reported the percentage of the diabetes was 59.6% in examined cases and the hypertension percentage was 14% in the cases, which was more than our results (hypertension, 36.67%; diabetes mellitus, 33.33%, and combined together, in 16.67% of cases). However, Nikam et al.[14] reported the diabetes was seen in 33% of the examined cases and Ghoneim et al.[13] recorded that 60% of the patients were hypertensive, which is in our range.

Regarding the type of dysfunctional fistula, Nassar et al.[17] found the rate of fistula types as follows: 63% radio cephalic, 12.7% brachioradialis, and 24.3% brachiocephalic fistula. However, Aktas et al.[16] found the rate of arm fistulae in the form of brachiobasilic was 3.9%, tracheobronchial was 0.4%, and brachiocephalic was 8.3% whereas the rate of forearm fistulae in the form of radiobasilic AVF was 0.4% and the radiocephalic was 86.8%. These results are in disagreement with our findings (radiocephalic in 20%, brachiocephalic in 56.67% and superficialized brachiobasilic in 23.33%), which was similar to Ghoneim et al. [13], who found 62% of patients had brachiocephalic AVF, 10% radiocephalic and 28% had brachioradial.

Moreover, we found the stenotic lesions were anatomically distributed as venous juxta-anastomotic stenoses in 40.91%, needling segment stenoses in 27.27%, anastomotic stenoses in 11.36%, and junctional stenotic lesions in 15.91%. Bountouris et al.[18] found the most common stenotic lesions in native AVF were cannulation segments in 49% and outflow vein in 18%. Lotfi and Mostafa[19] found the juxta-anastomotic segment in 30%, whereas the least common site was found in the proximal arterial segment (2.7%), needling segment (24.1%), anastomotic (13%), and junctional (6.3%), which was in agreement with our results.

In our results, the technical success rate reached 86.67% and failed to be dilated in 13.33% owing to either failure to cross the lesion in two cases that had totally occluded lesions at the anastomotic segment, another case of a tight stenotic lesion that failed to be dilated by conventional balloons, as well the last case had ruptured anastomosis. Meanwhile, other studies found lower rate than our results, such as Falk [20], who found a success rate was 74%, and Miquelin et al. [21], who reported 55%. However, others found higher rate than our results, Aktas et al.[16] found a successful procedure in 97.2% of cases and Nikam et al.[14] showed a success rate in 94% for AVFs. Moreover, Lotfi and Mostafa[19] found the anatomic success was achieved in 91.3% of patients. Moreover, the findings of Ghoneim et al.[13] came in agreement with our results, which found the technical success in 84%.

Moreover, the overall primary patency rates were 84.62 and 76.92% at 3 and 6 months, respectively. This is considered quite higher than Bountouris et al. [18], who recorded the primary patency of PTA was 61 and 42% at 3 and 6 months, respectively. Moreover, Nikam et al.[14] recorded primary patency rates of 76 and 64% at 3 and 6 months, respectively. In addition, a relatively similar result was obtained by Lotfi and Mostafa [19], who found a patency rate of 88.3 and 71.4% at 3 and 6 months, respectively, whereas Ghoneim et al.[13] reported a higher primary patency rate of 95% at 6 months. These differences may be owing to different duration of follow-up and distribution of our lesions.

Finally, it is important to have a proper strategy or protocol in each hospital to increase the longevity of the AVF, as this access could be the last option for dialysis. This protocol must involve and incorporate the efforts of the nephrologists, trained dialysis nurses, and vascular surgeons. Most importantly, this strategy is to be directed toward ensuring that every created fistula has the opportunity to mature and become a functional access and also ensure that every functioning fistula has the best opportunity for longevity. The paper work and financial procedures related to health insurance should be facilitated and sped up, as the cost of these operations is relatively high [22].

Limitations of this study

Our study had certain limitations, including the number of patients was relatively small as well as relatively short follow-up duration.


  Conclusion Top


From our results, we concluded that PTA is considered as an effective primary option in treatment of stenotic lesions of AVF that are both clinically and angiographically significant and also effective in restoring the function of failing AVFs. Moreover, PTA has several advantages, as it can be considered more safe procedure owing to its low complication rate, being less invasiveness, being a shorter procedure, enables immediate dialysis without using of central venous catheter, reduces the risk of infection, does not exhaust the patient's veins and spares them for further use, and can be repeated several times before abandoning the fistula.

Recommendations

Objective monitoring and surveillance of each AVF on a regular basis with proper preprocedural assessment and usage of suitable tools and techniques can optimize the results according to each lesion site. Any staff involved in treatment of renal patients should be adequately trained, and continuous training programs should be conducted for access management and local protocols in each hospital involving the nephrologists, dialysis nurses, radiologists, and vascular surgeons. More adequately powered multicenter randomized trials with long follow-up are needed in the future, which could potentially change our conclusions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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