Advances in Endovascular Techniques to Treat Failing and Failed Hemodialysis Access

Abstract

ࡗ ࡗDuring the decade since JEVT was inaugurated, we have witnessed the growing application of endovascular techniques for arteriovenous (AV) access in parallel with the evolution of endovascular therapy for arterial pathology. To date, few if any technologies have compared with balloon angioplasty for treating venous anastomotic stenosis, the most common cause of access failure. Only one device, which incorporates the principles of access graft design and self-expanding stent technology, has been uniquely conceived for this pathology. The encapsulated polytetrafluoroethylene stent-graft has achieved reasonable preliminary results, but randomized data is forthcoming. Technology to clear the clot from a thrombosed graft continues to evolve, but will never be as cost-effective as simple balloon thrombectomy. However, the pressure placed on providers to perform all percutaneous interventions and move away from open techniques continues to fuel interest in this component of treatment. Finally, the pursuit of a completely percutaneous AV access continues. As with endovascular procedures in general, whether or not the procedure is cost-effective or time-consuming seems to take a back seat to the all-percutaneous approach that so many seem to converge upon. Moreover, as most autogenous fistulas and AV grafts can be created with minimal incisions under local anesthesia, the pursuit of a completely percutaneous access system seems more like an academic exercise than a practical application of technology. We must try and avoid the tendency to ''minimize invasiveness'' with technology that is maximally intensive (and expensive), such as limiting ourselves to only percutaneous methods. Given the increasing pressure to have an all autogenous access program, current techniques that apply well in prosthetic grafts will need to be modified to accommodate the different biology of a native fistula. Clearly, the enlarging end-stage renal disease population will continue to provide endovascular specialists with clinically challenging problems requiring new and revolutionary technology. J Endovasc Ther 2004;11(Suppl II):II-134-II-139

Rapid progression of finger gangrene in a hemodialysis patient: A case report

“…Risk factors for the development of HAIDI include diabetes, female gender, age >60 years, peripheral arterial disease, tobacco abuse, multiple previous ipsilateral access procedures, high-flow access, capacious outflow veins, use of the brachial artery for inflow, and prior history of HAIDI. 10 There is a wide spectrum of symptoms, including sensory loss, paresthesia, poikilothermia, pallor, diminished or absent distal pulses, muscle weakness, hand pain aggravated by hemodialysis, and tissue loss. The DRIL procedure has been considered the standard operation to manage HAIDI with high symptom resolution and access preservation rates.…”

Pulmonary Embolism Following Thrombolysis of Dialysis Access: Is Anticoagulation Really Necessary?

“…The restoration of blood flow through a thrombosed AVG was once limited to surgical thrombectomy until PT was developed as an alternative. Initially, percutaneous thrombolysis (PT) was achieved with pharmacologic therapy using thrombolytic agents (urokinase or tissue plasminogen activator) in either continuous intravenous infusion or by direct injection into the thrombus in a pulse‐spray manner known as pulse‐spray pharmacomechanical thrombolysis (PSPMT) (1).…”

HEMATOLOGY: ISSUES IN THE DIALYSIS PATIENT: Vascular Access Thrombosis Prophylaxis

“…Subsequent radiologic or surgical intervention with angioplasty, stenting, or revision can prevent an impending thrombosis (6,7). While surveillance and early intervention can prevent the immediate morbidity of urgent acute vascular access placement, hospitalization, or missed treatments associated with sudden access thrombosis, long‐term access patency after interventional procedures, particularly for polytetrafluoroethylene (PTFE) grafts and basilic vein transposition fistulas, remains poor (8).…”