Endovascular embolization in problematic hemodialysis arteriovenous fistulas: A nonsurgical technique

Abstract

Introduction: In the past, surgical techniques were considered gold standard practice for obliterating the accessory veins, reducing the flow across the high flowing arteriovenous fistulas (AVFs), or for closing the problematic hemodialysis AVFs. However, recently endovascular embolization has emerged as a safe and cost-effective alternative to these surgical techniques. In this study, technical and clinical success, and safety of endovascular embolization have been evaluated for accessory vein obliteration, flow reduction, and fistula closure in problematic AVFs using various embolizing agents. Methods: This is a retrospective study of patients with problematic hemodialysis AVFs, who underwent endovascular embolization for accessory vein obliteration, flow reduction, and AVF closure at our center from February 2017 to January 2019 with various embolic agents like vascular plugs (VP), thrombin, coils, and glue. Follow-up was done at 1 week, 3 months, 6 months, and annually thereafter. Results: In this study 30 patients with problematic hemodialysis AVFs [Left brachiocephalic fistula (BCF) ( n = 22), right BCF ( n = 4), and left radiocephalic fistula (RCF) ( n = 4)], underwent endovascular embolization for accessory vein obliteration ( n = 6), flow reduction ( n = 3), and AVF closure ( n = 21). Of the 6 patients undergoing embolization for obliteration of accessory collateral, 4 patients had nonmaturing AVFs and 2 patients had symptoms of venous hypertension (VH). Post embolization, all 4 AVFs matured over a month and symptoms of VH completely resolved within a week. Three patients who underwent embolization for flow reduction had patent AVF (on doppler) post procedure and they achieved adequate flow during dialysis with complete resolution of symptoms of VH. Out of 21 patients, who underwent endovascular closure, complete AVF thrombosis was seen in 18 patients only with the use of VP, while 4 patients required additional procedure to achieve complete thrombosis of AVF. Conclusion: Endovascular embolization in problematic hemodialysis AVF is a safe and cost-effective alternative to open surgical methods and vascular plug could be embolic agent of choice for AVF closure.

Iatrogenic left common carotid artery to right internal jugular vein arteriovenous fistula closure

“…3,9 Endovascular covered stent placement, embolization and occlusion have emerged as the most common approaches to dealing with symptomatic or otherwise unresolved AVF in the modern era instead of open surgical options. 7 Intervention is always associated with risk, which must outweigh passivity. Covered stenting of the affected artery can be an excellent option.…”

“…Cases of iatrogenic AVF due to IJV catheterization have been reported. 2 , 3 , 7 Droll and Lossing 3 cited three cases of AVF that had occurred between the right CCA and right IJV in 2004. They reported that the first AVF had occurred in 1976 from IJV catheter placement that had developed a fistula between the inferior thyroid artery and the IJV.…”

Synthetic Haemostatic Sealants: Effectiveness, Safety, and In Vivo Applications

“…The choice of tissue adhesive depended on the operator’s preference according to the access technique used (endovascular and/or surgical), the site to be treated, and the type of material required to activate a haemostatic process at the site concerned. The surgical procedure for packing an arteriovenous fistula for haemodialysis was always performed in the operating theatre [ 35 , 36 ]. Having identified the site of anastomosis between the vein and the artery (radius cephalic/humeral basilic) by ultrasound, local anaesthetic was infiltrated with an incision of the skin at the level of the distal part of the left forearm.…”

Expanded Polytetrafluoroethylene Membranes for Vascular Stent Coating: Manufacturing, Biomedical and Surgical Applications, Innovations and Case Reports

“…In these cases, it is important to intervene through urgent endovascular surgery to save the affected site and avoid the complications associated with haemodialysis catheters if thrombectomy of the fistula is unsuccessful [ 78 ]. An endovascular-covered stenthas emerged as the approach to treating symptomatic instead of open surgical options [ 79 , 80 ]. Dukkipati et al described the case of a patient on haemodialysis for 6 months ineligible for the creation of a fistula due to the suboptimal size of the vein.…”