The Treatment of Chronic Hemodialysis Vascular Access by Directional Atherectomy

Abstract

Directional atherectomy (DA) was developed as a new therapeutic modality for coronary artery disease. For the past 3 years, we have applied DA intervention to vascular access failure with either poor blood flow rate or high venous pressure. DA intervention was performed on 27 lesions of 16 hemodialyzed patients. A reduction of stenosis to less than 20% of that before treatment was judged a technical success, and the rate of technical success was 84%. All patients showed adequate blood flow rates after DA intervention, indicating initial success. Although restenotic events occurred frequently, repeated DA interventions could be performed successfully. The patency rate at 1 month after DA intervention was 100%, at 3 months 93%, at 6 months 92% and at 12 months 75%. The short-term patency rate of DA was more satisfactory than the results of percutaneous transluminal angioplasty as reported by several investigators. Regarding the site of stenosis, restenotic events were relatively fewer in the lesions occurring at the native vein compared to those at graft-venous anastomotic sites. Eccentric-type stenosis was also associated with fewer restenotic events than circumferential-type stenosis. These results suggest that eccentric-type stenosis at the native vein is the most suitable lesion for the application of DA intervention in terms of long-term patency. As no severe complications occurred after DA intervention, this would appear to be a useful therapeutic modality for the correction of vascular access failure.

ASDIN Original Investigations: How I Do It: Directional Atherectomy for In‐Stent Restenosis of a PTFE Arteriovenous Graft

“…Several previous studies have described the use of DA in the treatment of difficult hemodialysis access stenosis (8–11). Mizumoto et al.…”

“…Mizumoto et al. reported an enviable patency rate at 1 month after DA intervention of 100%, at 3 months 93%, at 6 months 92%, and at 12 months 75% (9). A study by Gray et al.…”

Treating Intractable Venous Stenosis: Present and Future Therapy

“…In hemodialysis access stenoses, where lesions are fibrocellular rather than atherosclerotic, removal of tissue with an atherectomy catheter at the time of angioplasty could be expected to offer little difference to the proliferative process eventually leading to restenosis. Despite several encouraging series describing high technical success with directional atherectomy in autogenous and synthetic access lesions (12–14), enthusiasm for this technique has been hampered by a lack of demonstrated benefit in long‐term patency.…”

Advances in Endovascular Techniques to Treat Failing and Failed Hemodialysis Access

“…Unfortunately, experience to date has been disappointing versus the results of balloon angioplasty alone. 27,28 Finally, based upon the success seen with coronary and peripheral arterial interventions for recurrent stenosis, brachytherapy with ionizing radiation is being evaluated as an adjunct for recurrent access stenoses. Currently, a randomized, double-blind trial of brachytherapy for AV access graft venous stenosis is underway, which will likely define the utility of this modality for access failure.…”