Treatment of failing arterio‑venous dialysis graft by angioplasty, stent, and stent graft: Two‑years analysis of patency rates and cost‑effectiveness

Abstract

The objective of this prospective randomized single-center study was to compare primary and secondary patency rates, number of percutaneous transluminal angioplasty (PTA) interventions and cost-effectiveness among PTA, deployment of a stent, or a stent graft in the treatment of failing arteriovenous dialysis grafts (AVG) due to restenosis in the venous anastomosis or the outflow vein. Altogether 60 patients with failing AVG and restenosis in the venous anastomosis or the outflow vein were randomly assigned to either PTA, placement of a stent (E-Luminexx ®) or stent graft (Fluency Plus ®). After the procedure, patients with stent or stent graft received dual antiplatelet therapy for the next three months. Follow-up angiography was scheduled at 3, 6, and 12 months unless requested earlier due to suspected stenosis or malfunction of the access. Subsequently, angiography was performed only if requested by the clinician. During a median follow-up of 22.4 (IQR=5.7) months patients with PTA, stent, or stent graft required 3.1±1.7, 2.5±1.7, or 1.7±2.1 (P= 0.031) secondary PTA interventions. The primary patency rates were 0, 18 and 65% at 12 months and 0, 18 and 37% at 24 months in the PTA, stent, and stent graft group respectively (P<0.0001). The cost of the procedures in the first two years was €7,900±€3,300 in the PTA group, €8,500±€4,500 in the stent group, and €7,500±€6,200 in the stent graft group (P= 0.45). We conclude that the treatment of failing dialysis vascular access by the deployment of a stent graft significantly improves its primary patency rates and decreases the number of secondary PTA interventions; however, the reduction in costs for maintaining AVG patency is not significant.

Risk factors for in-stent restenosis in maintenance hemodialysis patients with central venous occlusive disease and biomechanical assessment of stents

“…The material and density of stents and the simulation conditions are identical, showing that varied biomechanical effects of stents are derived from different configurations. Among three venous stents commonly used in treating central vein or HD-circuit stenosis/occlusion, [26][27][28][29][30] similar radial force and flexibility are observed in SMART and Luminexx stents. Although the best performance in stress and strain on stent among the three, the equivalent stress and strain on vessels of SMART stent are the highest in expansion, and the strain is uneven.…”

Covered stents versus balloon angioplasty for failure of arteriovenous access: a systematic review and meta-analysis

“…In total, in all eight relevant studies (all RCTs), we included 867 patients for meta-analysis, who all had AVGs. [11][12][13][14][15][16][17][18] The patient populations of the two results were overlapping. 15 17 All studies were RCTs (four multicentre and two single-centre trials).…”

“…There was no mention of allocation concealment in two out of the seven prospective studies. 15 17 Blinding of participants and personnel was not possible, and we therefore allocated this as high risk of bias. We did not identify any detection or attrition bias in any prospective studies.…”

Effect of the combination of percutaneous transluminal angioplasty and pharmacological thrombolysis on hemodialysis patients

“…This microinflammatory state is induced by the complementary system and endotoxins which activate the mononuclear macrophages, and triggers the release of many inflammatory factors. As the inflammatory response is aggravated, renal function continues to decline [17]. One study found [18] that patients who underwent maintenance hemodialysis had remarkably higher serum levels of TNF-α and IL-6 than normal controls.…”