The Role of Percutaneous Angioplasty in the Management of Chronic Hemodialysis Fistulas

Abstract

One hundred forty-one dilatations of stenotic lesions in dialysis access fistulas were performed. The initial success rate was 82%. The one-year patency rate was 45%, with a 2-year patency rate of 24%. Best results were obtained with a discrete stenosis at a graft-to-vein anastomosis. The procedure can be done on an outpatient basis and, although long-term results are poor, in appropriate patients multiple dilatations can be performed to keep a fistula functioning for many years.

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

“…Having shown a three-fold adjusted relative risk for restenosis after PTA by comparison with surgery, our study confirms the results of previous noncomparative studies that reported higher primary patency rates in surgical series than after dilation in failing forearm AVF (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)25,26,28). Moreover, the unadjusted 1-yr primary patency rates in our series (91 Ϯ 6% for surgery and 54 Ϯ 8% for PTA) compare favorably with the literature, which reports rates of 64 to 88% after preemptive surgery (12,19,25,26) and 16 to 79% after endovascular procedures (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18).…”

“…Moreover, the unadjusted 1-yr primary patency rates in our series (91 Ϯ 6% for surgery and 54 Ϯ 8% for PTA) compare favorably with the literature, which reports rates of 64 to 88% after preemptive surgery (12,19,25,26) and 16 to 79% after endovascular procedures (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18). In addition, restenosis rates after the two surgical techniques were similar in our study, failing to support the concern of any higher complication rates' being associated with the PTFE interposition graft (24).…”

“…In recent years, endovascular techniques have become the firstline treatment for AVF dysfunction and have replaced the classical surgical approach in many centers because they are less invasive, they preserve native vessels better, the access can continue to be used, and the success rates are excellent. They suffer from a high restenosis rate, however, and require repeated intervention to maintain patency (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18) and have been found by some authors to be less successful in treating long (Ն3 cm) or critical (Ն90% reduction in luminal diameter) stenoses (5,14).…”

“…The surgical correction of stenosis-creating a more proximal neo-anastomosis (2,12,19,(22)(23)(24)(25)(26), vein-to-vein re-anastomosis (19,23), vein patching (12,23,26,27), or short vein (12,22,23,27) or PTFE graft interposition (12,19,24,26,27)-is a minimally invasive procedure in such easily accessible vessels, it does not use up a long segment of the vein, it involves minimal intimal trauma, and it is likely to be more durable than percutaneous transluminal angioplasty (PTA), because reported primary patency rates in surgical series are higher than after dilation (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(23)(24)(25)(26)28). Some investigators use PTA as the first-line treatment for these lesions, too, however, because it is less invasive and produces excellent immediate primary results …”

Plasma ADMA Predicts Restenosis of Arteriovenous Fistula

“…Although PTA is effective in treating stenotic lesions in dialysis fistulas, its benefit could be attenuated by a high restenosis rate within 6 mo. 10,11 The mechanisms of restenosis in arterial systems have been widely investigated; however, direct application of these mechanisms to the venous segment of AVFs may not be valid. At the anatomic level, veins tend to have a less well-defined internal elastic lamina.…”