The Eternal Tale of Dialysis Access Vessels and Restenosis: Are Drug-Eluting Balloons the Solution?

Abstract

In dialysis access fistulas and grafts, percutaneous transluminal angioplasty (PTA) is frequently followed by restenosis development, which results in repeated periodical re-interventions. The technique of drug-eluting balloon (DEB) angioplasty has shown promising results in the treatment of femoropopliteal arteriosclerotic lesions. In contrast to arteriosclerotic arteries, dialysis access vessels host unfavorable hemodynamics due to the direct conduction of high-pressure fluid into a low-pressure system. Hence, the beneficial effect of DEB angioplasty may be limited in this system. However, a first prospective randomized trial on 40 patients with arteriovenous fistula or graft stenoses exhibited a significantly higher 6-month primary patency of the treated lesions after DEB angioplasty than after uncoated balloon angioplasty. Despite such a positive reference, general recommendations regarding the value of DEBs in dialysis access vessels cannot be considered as serious unless large randomized controlled trials have been performed.

Editor's Choice – Vascular Access: 2018 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS)

“…Therefore, until long-term results are published the use of stent grafts can only be recommended when it is considered unavoidable by an endovascular specialist. The role of drug eluting balloons (DEB) is currently being examined and may offer an alternative to stents in VA. 539,540 A small RCT showed that DEB angioplasty may be a costeffective option that significantly improves patency after angioplasty of venous stenoses of failing VA. 541 Since the outflow anastomosis can be considered as an experimental model for NIH, future research direction may clarify whether DEBs may offer an alternative to stents in VA.…”

Future research directions to improve fistula maturation and reduce access failure

“…Despite surgical revision having traditionally been the most effective treatment of local disease, the current standard treatment for arteriovenous stenosis is percutaneous transluminal angioplasty (PTA) [177] [12]. Although PTA can improve patency and function in some cases of thrombosis and stenosis, PTA is not the optimal treatment for many lesions including resistant or recurrent stenosis [178]. This section of the review focuses on treatment of AVF access failures, broadly dividing them into stimulatory and inhibitory treatments, with further division into endovascular approaches, perivascular approaches and internal/external support devices.…”

Platelet to lymphocyte ratio predicting 6-month primary patency of drug-coated balloon for femoropopliteal disease

“…It is known that DCB with antiproliferative drugs has the effect of inhibiting intimal hyperplasia and reducing the occurrence of restenosis [31]. However, in complex FPD including severe calcium, long segment lesions, the applications of DCB angioplasty are often excluded for lesions with flow-limiting dissection or high residual narrowing after pretreatment with uncoated balloon, and bail-out stenting has to be used in some cases [32].…”