<i>Opinion</i>: Is Percutaneous Transluminal Angioplasty an Effective Intervention for Arteriovenous Graft Stenosis?

White, John J.; Bander, Steven J.; Schwab, Steve J.; Churchill, David; Moist, Louise; Beathard, Gerald A.; Vesely, Thomas M.; Paulson, William D.; Huber, Thomas S.

doi:10.1111/j.1525-139x.2005.18307.x

Cited by 31 publications

(27 citation statements)

References 10 publications

(17 reference statements)

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“…Another important issue is that the influence of luminal diameters on Q addresses only one potential contributor to the poor results of surveillance. For example, it does not address whether preemptive angioplasty is an effective treatment once Q surveillance has identified stenosis (14). It is possible that even if measurements were done more frequently, outcomes might not be improved.…”

Section: Resultsmentioning

confidence: 99%

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Influence of Luminal Diameters on Flow Surveillance of Hemodialysis Grafts

White

Ram

Jones

et al. 2006

Clinical Journal of the American Society of Nephrology

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Randomized controlled trials have not shown that surveillance of graft blood flow (Q) prolongs graft life. Because luminal diameters affect flow resistance, this study examined whether the influence of diameters on Q can explain the limitations of surveillance. Inflow artery and outflow vein diameters were determined from duplex ultrasound studies of 94 patients. These diameters were applied to a mathematical model for determination of how they affect the relation between Q and stenosis. Also determined was the correlation between Q (by ultrasound dilution) and diameters, stenosis, and mean arterial pressure in 88 patients. Artery and vein diameters varied widely between patients, but arteries generally were narrower than veins. The model predicts that the relation between Q and stenosis is sigmoid: as stenosis progresses, Q initially remains unchanged but then rapidly decreases. A narrower artery increases flow resistance, causing a longer delay followed by a more rapid reduction in Q. In a multiple regression analysis of data from patients, Q correlated with artery and vein diameters, sum of largest stenoses from each circuit segment, and mean arterial pressure (R ‫؍‬ 0.689, P < 0.001). This study helps to explain why Q surveillance predicts thrombosis in some patients but not others. Luminal diameters control the relation between Q and stenosis, and these diameters vary widely. During progressive stenosis, the delay and then rapid reduction in Q may impair recognition of low Q before thrombosis occurs. Surveillance outcomes might be improved by taking frequent measurements so that there is no delay in discovering that Q has decreased.

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Section: Resultsmentioning

confidence: 99%

“…In our patients, 44% of thromboses occur without a preceding reduction in Q (10,11). Consequently, the efficacy of flow surveillance has been debated at several recent nephrology symposia and in the literature (12)(13)(14).…”

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confidence: 99%

Influence of Luminal Diameters on Flow Surveillance of Hemodialysis Grafts

White

Ram

Jones

et al. 2006

Clinical Journal of the American Society of Nephrology

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“…The most common cause of dysfunction or loss of the arteriovenous access is thrombosis in the low flow state (2). The patency of arteriovenous grafts (AVGs) and arteriovenous fistulae (AVF) is compromised mainly by intimal hyperplastic lesions, which usually develop in areas of turbulent flow.…”

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confidence: 99%

Stent Placement Versus Angioplasty Improves Patency of Arteriovenous Grafts and Blood Flow of Arteriovenous Fistulae

Chan

Bedi

Sanchez

et al. 2008

Clinical Journal of the American Society of Nephrology

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Background: While endovascular stent placement is the standard of care in most percutaneous coronary and peripheral artery intervention, its role in the salvage of thrombosed and stenotic hemodialysis access remains controversial.Design, Setting, Participants, and Measurements: We compared the effects of stent versus angioplasty on primary patency rates in the treatment of stenotic arteriovenous fistulae (AVF) and arteriovenous grafts (AVGs). Moreover, we compared access flow (Qa) and urea reduction ratio (URR) between the two groups as a metric of the effect of stent placement versus angioplasty on dialysis delivery.Results: Cox regression analysis revealed that the primary assisted AVG patency was significantly longer for the stent group compared with angioplasty, with a median survival of 138 versus 61 d, respectively (aHR ‫؍‬ 0.17; 95% confidence interval, 0.07 to 0.39; P < 0.001). The primary AVG patency for stent versus angioplasty was 91% versus 80% at 30 d, 69% versus 24% at 90 d, and 25% versus 3% at 180 d, respectively. The primary assisted AVF patency did not differ significantly between the stent and angioplasty groups. In patients dialyzing via AVF, multiple regression analysis revealed that stent placement was associated with improved after intervention peak Qa, 1627.50 ml/min versus 911.00 ml/min (␤ ‫؍‬ 0.494; P ‫؍‬ 0.008), change in Qa from before to after intervention, 643.54 ml/min versus 195.35 ml/min (␤ ‫؍‬ 0.464; P ‫؍‬ 0.012), and change in URR from before to after intervention, 5.85% versus 0.733% (␤ ‫؍‬ 0.389; P ‫؍‬ 0.039).Conclusions: Our results suggest that stent placement is associated with improved AVG primary assisted patency and improved AVF blood flow, which may significantly impact on dialysis adequacy.

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“…This may not be a surprise because in grafts and fistulas, angioplasty is a common intervention and is considered a controlled injury to the vessel wall, contributing to accelerated stenosis and need for repeat intervention at increasing frequency rate. 13 The increased rates of early noninfectious catheter complications have also been described. 14 Xue et al reported use of tissue plasminogen activator and rate of catheter replacement use of 6.38 and 1.05, respectively, per 1000 accessdays over 1 year, with a higher rate of intervention in the first 90 days.…”

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confidence: 99%