Aim:to analyze the results of the regional center for the creation and maintenance of vascular access for hemodialysis.Materials and methods.We performed a retrospective analysis. In five years (2012–2016) we performed 3,837 different operations on vascular access (VA) in 1,862 patients.Results.There is a strong dependence of type VA and the cause of CKD 5D. At the time of the HD start, the proportion of arteriovenous fistula (AVF), synthetic vascular graft (SVG) and central venous catheter (CVC) was 73.7, 0.3 and 26% for glomerulonephritis; 58.4, 0.4 and 41% for pyelonephritis; 53, 1 and 26% for diabetes mellitus; 32, 8 and 60% for polycystic disease and 33, 2 and 65% for systemic processes, respectively. After one year on HD the shares of AVF, SVG and CVC were 89, 2 and 9% for glomerulonephritis; 76, 6 and 18% of pyelonephritis; 70, 5 and 25% for diabetes mellitus; 68, 10 and 22% for polycystic disease and 53, 5 and 42% for systemic processes, respectively. In a case of start of HD via AVF, five years survival was 61% [95% CI 51.8; 71.9]; in a case of start HD via CVC with followed by conversion to AVF – 53.9% [95% CI 42.5; 67]; in a case of CVC remained the only access – 31.6% [21.4; 41.4]. Non-maturation of AVF was observed in 5.9% of new AVF (the risk increased in a case of diabetes mellitus), early thrombosis (before the first use of AVF) was observed in 12.7% of new AVF (the risk increased with diabetes, polycystic and systemic diseases). Creation of AVF a week before the start of HD or 1–2 weeks later significantly increased the risk of thrombosis. Primary patency in a year, three and five years was 77.2% (95% CI 71.7; 81.7); 48% (95% CI 41.6, 54.1); 34.1% (95% CI 27.8, 40.5) respectively; secondary patency – 87% [95% CI 83.7; 89.7]; 74.4% [95% CI 70.3; 78,12]; 60.9% [95% CI 56.4; 65.1] respectively. The use of temporary CVC is associated with a three-fold increase of the risk of infection compared with permanent CVC: IRR 3,31 (2,46; 4,43), p < 0,0001.Conclusion.A more detailed analysis is required to identify risk factors for complications of vascular access and to optimize approaches to its creation and maintenance.

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Vascular access is the cornerstone of hemodialysis. With vascular access dysfunction, the results of treatment of patients with stage 5 chronic kidney disease significantly deteriorate. One of the most common causes of vascular access failure is peripheral venous stenosis. Despite the variety of initiating factors, the morphological substrate of stenotic damage to the arteriovenous fistula (or arteriovenous anastomosis) in most cases is neointimal hyperplasia. Stenotic lesions of the arterivenous fistula are strongly associated with an increased risk of thrombosis and loss of vascular access. There are 4 typical localizations of stenosis: arteriovenous or arteriograft anastomosis, stenosis of the juxta-anastomotic segment of the fistula, stenosis of the functional segment of the fistula, and stenosis of the cephalic arc.The most common indication for surgical treatment is vascular access failure; less common indications are clinical symptoms of venous insufficiency.There are various methods of open reconstruction of the stenotic segment of the fistula vein: resection, prosthetics with a synthetic vascular graft, prosthetics or plastic repair of the autologous vein wall, complete or partial drainage of the prestenotic segment of the vein, etc. Currently an alternative method of stenosis repair using endovascular interventions is gaining popularity. In contrast to central vein stenosis, where endovascular interventions are the gold standard, in peripheral vein stenosis it is only an adjuvant method. Complications of endovascular interventions are extremely rare.Despite the fact that endovascular interventions have almost absolute probability of technical success, the primary patency is not high and is about 50% in six months. The use of bare stents is not accompanied by an increase in primary patency. The use of stent-grafts can increase the primary patency, especially in the plastic repair of challenging stenoses of the graft-vein anastomosis or cephalic arch.Many issues related to endovascular interventions remain unresolved, which requires further research.

Цель. Провести сравнительный анализ результатов изолированной баллонной ангиопластики и ангиопластики со стентированием при стенозе центральных вен у пациентов на гемодиализе. Материалы и методы. В ретроспективное исследование включены 62 пациента со стенозом центральных вен (СЦВ). У 39 пациентов выполнена изолированная баллонная ангиопластика (БА), у 23 пациентов БА дополнена стентированием. Результаты. Функциональная первичная проходимость артериовенозной фистулы через 1 и 3 года после БА: 89,7% [95%ДИ 74,9; 96] и 30,8% [95%ДИ 17,3; 45,4], после стентирования: 100% и 30,4% [95%ДИ 13,5; 49,3]; HR=0,8756 [95%ДИ 0,527; 1,455], p=0,5994. Первичная проходимость через 6 и 12 месяцев после БА: 61,5% [95%ДИ 44,5; 74,7] и 15,4% [95%ДИ 6,2; 28,3]; после стентирования: 82,6% [95%ДИ 60,1; 93,1] и 47,8% [95%ДИ 26,8; 66,1]; HR=0,4845 [95%ДИ 0,2938; 0,799], p=0,0017. Функциональная вторичная проходимость через 1, 3 и 4 года после БА: 100%, 74,4% [95%ДИ 57,6; 85,3] и 12,8% [95%ДИ 4,7; 25,2]; после стентирования: 100%, 91,3% [95%ДИ 69,5; 97,8] и 34,8% [95%ДИ 16,6; 53,7]; HR=0,4764 [95%ДИ 0,2888; 0,786], p=0,0016. Вторичная проходимость через 6, 12 и 24 месяца после БА: 84,6% [95%ДИ 68,9; 92,8], 66,7% [95%ДИ 49,6; 79,1] и 17,9% [95%ДИ 7,9; 31,3]; после стентирования: 91,3% [95%ДИ 69,5; 97,8], 78,3% [95%ДИ 55,4; 90,3] и 43,5% [95%ДИ 23,3; 62,1]; HR=0,4925 [95%ДИ 0,2988; 0,8119], p=0,0021. Корреляция функциональной первичной проходимости с первичной проходимостью составила r= -0,627; р<0,0001, с вторичной проходимостью – r= -0,53; р=0,0005 при БА, при стентировании – r= -0,351; р=0,101 и r= -0,304; р= 0,159 соответственно. Заключение. Результаты БА существенно зависят от давности стеноза. Применение стентов позволяет улучшить результаты вне зависимости от давности стеноза. Научная новизна статьи впервые доказано, что период времени между началом использования артериовенозной фистулы для гемодиализа и клинической манифестацией стеноза центральных вен оказывает существенное влияние на результаты эндоваскулярных вмешательств. Установлено, что эффективность баллонной ангиопластики значительно снижается при коррекции «поздних» стенозов. Применение стентов позволяет несколько улучшить результаты эндоваскулярных вмешательств при стенозе центральных вен вне зависимости от давности стеноза.

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Background and Aims Balloon angioplasty (BA) without the use of stents has unsatisfactory results, which may cast doubt on its expediency. At the same time, BA is a very expensive treatment method. We conducted a comprehensive comparative analysis of the native arteriovenous fistula (AVF) patency rates in hemodialysis patients with central venous stenosis (CVS) after endovascular BA and «open» palliative surgery. Method A retrospective study included 80 patients with confirmed central vein stenosis: subclavian, brachiocephalic veins, vena cava inferior, or multiple lesions. The main group included 39 patients who underwent percutaneous balloon angioplasty. The control group included 41 patients who did not have balloon angioplasty for various reasons. In this patients we performed only «open» palliative interventions: thrombectomy, proximalization of arteriovenous anastomosis, AVF blood flow reduction. Results Functional primary patency (the time interval between the start of AVF using and the first intervention) did not differ: groups were comparable in time of stenosis manifestation (fig. 1A). Primary patency (the time interval between the first and second interventions) after BA was statistically significantly better than in the main group (fig. 1B), but difference was minimal: median survival in the study group of 8 months [95% CI 6; 10] vs. - 6 months [95% CI 4.9; 7.1]. There was the strong negative correlation between the primary patency and functional primary patency in the main group (r = –0.627 [95%CI –0.787; –0.388], p &lt;0.0001) but not in the control group (r = 0.049 [95%CI –0.262; –0.351], p = 0.7599). Thus, the later manifestation of CVS related with lower effectiveness of BA. The functional secondary patency (total duration of AVF use) in the main group was significantly better: median survival was 47 months [95% CI 40.9; 53.1] vs. 34 months [95% CI 29.8; 38.2] as well as secondary patency (the time interval between the first intervention and the complete cessation of AVF use): median survival was 16 months [95% CI 12.5; 19.5] vs. 7 months [95% CI 4.9; 9.1] (fig. 1 C and D). The occlusion-free period from the moment of starting the AVF use (functional primary assisted patency – fig. 1E) was higher in the main group, but difference was minimal: median survival was 39 months [95% CI 36.5; 41.5] vs. 32 months [95% CI 27.5; 36.5], as well as occlusion-free period from the moment of the first surgical intervention (primary assisted patency – fig. 1F) median survival was 9 months [95% CI 7; 11], in the control group - 7 months [95% CI 5.6; 8.4]. The need for open interventions was lower in the main group: 0.374 [95% CI 0.24; 0.556] and 2.451 [95% CI 1.1963; 3.023] per 10 patient-months, incidence rate ratio (IRR)= 0.153 [95% CI 0.095; 0.237], р&lt;0.0001; as well as overall need for interventions: 1.511 [95% CI 1.225; 1.843] and 2.451 [95% CI 1.963; 3.023] per 10 patient-months, IRR 0.617 [95% CI 0.461; 0.825] p=0.0011. The value of AVF volume blood flow had a strong negative correlation with the primary patency in both groups (r = –0.529, p =0.0027; r = –0.419, p =0.0101). Conclusion 1. Central vein stenosis is inevitably leads to loss of vascular access on the ipsilateral side. 2. Balloon angioplasty allows to extend the period of AVF use but it is not a radical treatment method of CVS. 3. The results of balloon angioplasty are significantly affected by the length of the period from the start of AVF use to the CVS manifestation. 4. Multiple repeated BA are apparently justified in patients for whom the possibility of creating a new vascular access is doubtful. 4. The AVF volume blood flow is an important factor determining the severity of CVS clinical manifestations and the need for repeated surgical interventions.