Endovascular versus Surgical Preemptive Repair of Forearm Arteriovenous Fistula Juxta-Anastomotic Stenosis

Abstract

Surgery is the traditional treatment for juxta-anastomotic stenoses in forearm arteriovenous fistulas (AVF), but percutaneous transluminal angioplasty (PTA) is a suitable alternative. No prospective comparative trials between the two have been reported to date, however. A retrospective analysis of prospectively, concurrently collected data was performed to compare the outcome and cost of surgery and PTA in the preemptive repair of juxta-anastomotic stenosis in lower forearm AVF. Sixty-four AVF with >50% venous juxta-anastomotic stenosis were considered: 21 were treated surgically (11 proximal neo-anastomosis and 10 polytetrafluoroethylene interposition graft) and 43 by PTA. After treatment, AVF were monitored by quarterly ultrasound dilution access blood flow measurement. End points were restenosis and procedure failure rate (re-intervention by another technique or access loss), and determinants were analyzed using Cox hazard model. Initial procedural success was 100% for surgery and 95% for PTA (P ‫؍‬ 0.539). Restenosis rate was 0.168 and 0.519 events/AVF-year for surgery and PTA, respectively (P ‫؍‬ 0.009). The type of procedure was the only variable that was significantly associated with restenosis, the adjusted relative risk being 2.77-fold higher (95% confidence interval 1.07 to 7.17; P ‫؍‬ 0.036) after PTA than surgery. The procedure failure rate was 0.110 and 0.097 events/AVF-year for surgery and PTA, respectively (P ‫؍‬ 0.736). The cost profile also was similar for the two procedures. This prospective comparative study confirms a higher restenosis rate after PTA than surgery, but with strict surveillance for restenosis, the two procedures show similar assisted primary patency and cost, suggesting that they should be considered equally valid, complementary alternatives in the preemptive treatment of juxtaanastomotic stenosis in forearm AVF.

Endovascular Treatment of Juxta-anastomotic Venous Stenoses of Forearm Radiocephalic Fistulas: Long-term Results and Prognostic Factors

“…Unfortunately, little is known about the prognostic factors that directly influence the FEI. Indeed, most published series have evaluated prognostic factors influencing the PP rate (ie, delay of first restenosis) (1,3,4,6,16,17) or the APP/SP rate (ie, long-term patency regardless of the number of interventions) (3,4,6,12,13). To our knowledge, only one study (4) assessed the influence of AVF location on FEI, and it found a significantly higher rate of interventions in brachiocephalic (0.77/y) than in radiocephalic (0.41/y) AVFs.…”

“…Moreover, little is known about the prognostic factors that could influence the outcome of endovascular procedures in the specific group of JASs of forearm stenoses. One study could not identify any significant prognostic factor (16), whereas a stenosis at the anastomotic site itself and smoking significantly increased the risk of restenosis in another (17). Therefore, we undertook the present study to assess the long-term outcome of endovascular treatment of JASs in forearm AVFs, and to identify potential prognostic factors of failure that could orient patients toward first-line surgical management.…”

“…As a consequence, the results obtained specifically in JASs of forearm AVFs seldom have been reported, with 1-year PP and APP/SP rates of 41%-60% and 64%-96%, respectively (6,(15)(16)(17). Moreover, little is known about the prognostic factors that could influence the outcome of endovascular procedures in the specific group of JASs of forearm stenoses.…”

Efficacy of Percutaneous Transluminal Angioplasty on Dysfunctional Fistulae Because of Inflow Stenosis

“…Venous problems have been regarded as the principal culprits for access dysfunction for a long time, with much less importance given to inflow problems which had an incidence of 0% to 4% (12). Although, in the last few years, inflow stenoses have been shown to be present in approximately 25% to 50% of the dysfunctional access (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26). Both radiocephalic and brachiocephalic fistulas commonly fail because of lesions located within the perianastomotic region; however, more proximal stenoses can also occur in both cases, especially in the case of brachiocephalic fistulas (cephalic arch stenosis) (27).…”

Vascular Access for Dialytic Therapies

“…36 Restenosis rates were significantly higher after angioplasty, but overall costs of treatment were similar. Nonmatured fistulas are rescued by angioplasty of stenoses or occlusions, ligation of accessory veins, or both.…”