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Metallic Stent Placement for Treating Peripheral Outflow Lesions in Native Arteriovenous Fistula Hemodialysis Patients After Insufficient Balloon Dilatation

Huay-Ben Pan1,2, Huei-Lung Liang1,2, Yih-Huie Lin1,2, Hsiao-Min Chung2,3, Tung-Ho Wu2,4, Chiung-Yu Chen1,2, Hua-Chang Fang2,3, Clement K.-H. Chen1,2, Pin-Hon Lai1,2 and Chien-Fang Yang1,2

1 Department of Radiology, Kaohsiung Veterans General Hospital, 386 Ta-Chung 1st Rd., Kaohsiung, Taiwan 813, ROC.
2 Department of Radiology, National Yang-Ming University, Taipei, Taiwan 813, ROC.
3 Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan 813, ROC.
4 Department of Vascular Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan 813, ROC.



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  		Fig. 1A. —77-year-old woman with radiocephalic fistular access at left forearm. Retrograde contrast injection shows outflow vein with proximal dilated side-branch collateral (arrow). Lower outflow vein could not be canalized due to tight stenosis coexisting with side-branch vein.

 


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  		Fig. 1B. —77-year-old woman with radiocephalic fistular access at left forearm. Antegrade contrast injection via puncture of lower outflow vein revealed tight venous stenosis (arrow) in vascular access. AVA = arteriovenous anastomosis; RA = radial artery.

 


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  		Fig. 1C. —77-year-old woman with radiocephalic fistular access at left forearm. After balloon dilatation via retrograde fashion, an intima flap (D, arrow) floating in venous lumen was noted in both sonographic image and venogram.

 


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  		Fig. 1D. —77-year-old woman with radiocephalic fistular access at left forearm. After balloon dilatation via retrograde fashion, an intima flap (D, arrow) floating in venous lumen was noted in both sonographic image and venogram.

 


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  		Fig. 1E. —77-year-old woman with radiocephalic fistular access at left forearm. After short stent placement for dissection, access was kept patent for 15 months (primary) until end of the study.

 


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  		Fig. 1F. —77-year-old woman with radiocephalic fistular access at left forearm. After short stent placement for dissection, access was kept patent for 15 months (primary) until end of the study.

 


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  		Fig. 2A. —54-year-old woman with radiocephalic access at left forearm in place less than 2 months. Retrograde catheterization failed to canalize obliterated outflow vein. Venogram via puncture of distal radial artery (A, arrowhead) shows obliterated segment (A and B, arrow) of outflow vein. Perforation with contrast medium extravasation (B, arrowhead) in small side branch during wire canalization was noted. Perforation disappeared spontaneously after main outflow vein was opened. AVA = arteriovenous anastomosis; RA = radial artery.

 


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  		Fig. 2B. —54-year-old woman with radiocephalic access at left forearm in place less than 2 months. Retrograde catheterization failed to canalize obliterated outflow vein. Venogram via puncture of distal radial artery (A, arrowhead) shows obliterated segment (A and B, arrow) of outflow vein. Perforation with contrast medium extravasation (B, arrowhead) in small side branch during wire canalization was noted. Perforation disappeared spontaneously after main outflow vein was opened. AVA = arteriovenous anastomosis; RA = radial artery.

 


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  		Fig. 2C. —54-year-old woman with radiocephalic access at left forearm in place less than 2 months. After balloon dilatation (5 mm) of obliterated segment, the dilatation was complicated by rupture with prominent contrast medium extravasation (arrow).

 


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  		Fig. 2D. —54-year-old woman with radiocephalic access at left forearm in place less than 2 months. Metallic stent was deployed but small contrast leakage (arrow) still was noted. Arrowhead shows retrograde entry site.

 


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  		Fig. 2E. —54-year-old woman with radiocephalic access at left forearm in place less than 2 months. Diagram shows obliterated segment of outflow vein in this immature access. Curved arrows show site of both ante- and retrograde puncture of the access. RA = radial artery; R = site of vascular rupture; S = stent location.

 


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  		Fig. 3A. —43-year-old woman with two large thrombosed aneurysms at left forearm. After initial thrombolysis and balloon dilatation, large residual adherent thrombus within two aneurysms was noted (arrows).

 


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  		Fig. 3B. —43-year-old woman with two large thrombosed aneurysms at left forearm. After infusion of total dose of 600,000 IU urokinase into the lower aneurysm, the access was examined by color sonography; images showed complete clearance of aneurysm (A). BII and III: Large residual thrombus (T) in the upper aneurysm was demonstrated.

 


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  		Fig. 3C. —43-year-old woman with two large thrombosed aneurysms at left forearm. After placement of metallic stent (arrow) in partially recanalized upper thrombosed aneurysm, access was kept patent (secondary) for 12 months, until end of the study.

 


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  		Fig. 4A. —Three patients with stents involving anastomosis. Venograms show recoil stenosis (A, arrow) of peripheral outflow near arteriovenous anastomosis (AVA) after balloon dilatation in 77-year-old man. Insufficient flow volume was complicated due to overstenting of Wallstent (Boston Scientific) into distal radial artery (DRA). RA = radial artery.

 


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  		Fig. 4B. —Three patients with stents involving anastomosis. Venograms show recoil stenosis (A, arrow) of peripheral outflow near arteriovenous anastomosis (AVA) after balloon dilatation in 77-year-old man. Insufficient flow volume was complicated due to overstenting of Wallstent (Boston Scientific) into distal radial artery (DRA). RA = radial artery.

 


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  		Fig. 4C. —Three patients with stents involving anastomosis. 42-year-old woman with radiocephalic fistula in left forearm. A nitinol stent was deployed with 2–3 mm protruding into anastomosis (arrow, C). The follow-up venogram 14 months after stent placement revealed retrograde blood supply from ulnar artery to vascular access. UA = ulnar artery; RA = radial artery; DRA = distal radial artery. E and F, 71-year-old woman with radiocephalic fistula in left forearm. Recoil stenosis (arrow, E) of peripheral outflow near arteriovenous anastomosis (AVA) after balloon dilatation was noted. Wallstent was deployed across anastomosis into supplying radial artery. Access was maintained patent for 22 months (secondary), until the end of the study. RA = radial artery.

 


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  		Fig. 4D. —Three patients with stents involving anastomosis. 42-year-old woman with radiocephalic fistula in left forearm. A nitinol stent was deployed with 2–3 mm protruding into anastomosis (arrow, C). The follow-up venogram 14 months after stent placement revealed retrograde blood supply from ulnar artery to vascular access. UA = ulnar artery; RA = radial artery; DRA = distal radial artery.

 


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  		Fig. 4E. —Three patients with stents involving anastomosis. 71-year-old woman with radiocephalic fistula in left forearm. Recoil stenosis (arrow, E) of peripheral outflow near arteriovenous anastomosis (AVA) after balloon dilatation was noted. Wallstent was deployed across anastomosis into supplying radial artery. Access was maintained patent for 22 months (secondary), until the end of the study. RA = radial artery.

 


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  		Fig. 4F. —Three patients with stents involving anastomosis. 71-year-old woman with radiocephalic fistula in left forearm. Recoil stenosis (arrow, E) of peripheral outflow near arteriovenous anastomosis (AVA) after balloon dilatation was noted. Wallstent was deployed across anastomosis into supplying radial artery. Access was maintained patent for 22 months (secondary), until the end of the study. RA = radial artery.

 


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  		Fig. 5. —Diagram shows primary and secondary patency rates of hemodialysis access after metallic stent placement in native arteriovenous fistula patients.

 

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