AJR 2005; 184:403-409
© American Roentgen Ray Society
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.
Received February 29, 2004;
accepted after revision June 22, 2004.
Supported by a grant from Kaohsiung Veterans General Hospital
(VGHKS90-55).
Address correspondence to H-L Liang
(hlliang{at}isca.vghks.gov.tw).
Abstract
OBJECTIVE. The purpose of this study was to report our experience
with metallic stent placement in the peripheral outflow veins in native
arteriovenous fistula (A-V fistula) hemodialysis patients after insufficient
balloon dilatation.
MATERIALS AND METHODS. During the past 4 years, 12 A-V fistula
dialysis patients in our hospital underwent metallic stent placement in the
peripheral outflow veins to restore vascular access. The indications for
metallic stent placement in our study included (1) recoil stenosis of outflow
vein in six patients; (2) outflow venous rupture in two patients and
dissection in one patient; and (3) large residual adherent thrombus in outflow
aneurysms in three patients with thrombosed (arteriovenous) access.
Self-expandable Wallstent or Jostent (Jomed, Abbott Laboratories) of
appropriate size (6–10 mm in diameter) was chosen for use in these
patients. Kaplan-Meier survival analysis was used to calculate the access
patency rates.
RESULTS. Twelve patients received stents. Eleven patients (92%)
underwent successful dialysis after the procedure. One patient experienced
complications due to incorrect positioning of the stent at the anastomotic
site, causing flow compromise. The primary patency (± standard error)
of the vascular access at 3, 6, 12, and 24 months was 92% ± 8%, 81%
± 12%, 31% ± 17%, and 31% ± 17%, respectively. The
secondary patency of the vascular access at 3 months was 92% ± 8%, and
82% ± 12% at 6, 12, and 24 months each.
CONCLUSION. Metallic stent placement is safe and effective in
treating peripheral venous lesions in native A-V fistula hemodialysis patients
after unsatisfactory balloon dilatation.
Introduction
Percutaneous transluminal angioplasty has become the treatment of choice
for most dysfunctional vascular access in hemodialysis patients. The high
technical success of percutaneous transluminal angioplasty in both
dysfunctional polytetrafluoroethylene (PTFE) grafts and native arteriovenous
fistulas (A-V fistulas) has been reported
[1–6].
Early failure of the access after simple balloon dilatation may occur in some
of the patients in whom metallic stent placement is considered mandatory for
nonsurgical maintenance of the access. For peripheral outflow lesions, most
investigators have reported metallic stent use in PTFE graft patients
[7–11].
Only a few articles have mentioned its clinical application in native A-V
fistula patients
[12–17].
In articles by Petar et al.
[12], Antonucci et al.
[13], and Farber et al.
[14], only small number of
patients with native A-V fistula was included (five, seven, and five patients,
respectively). In the three other studies, 11 to 15 patients'A-V fistula
accesses were reported as being salvaged by metallic stent placement
[15–17].
In this article, we report our experience of metallic stent placement in
treating peripheral outflow lesions in 12 A-V fistula patients after
insufficient balloon dilatation.
Materials and Methods
From March 1999 to April 2003, 12 A-V fistula dialysis patients underwent
metallic stent placement in the peripheral outflow veins and were
retrospectively reviewed in our hospital. There were six male and six female
patients aged 42–83 years (mean, 57.6 years) with nine thrombosed and
three stenotic A-V fistulas. The length of time the vascular access had
existed at the time of stent placement was available in 10 (83%) patients with
the average duration of 19.6 months (range, 2–72 months). Prior
percutaneous angioplasty for the same accesses (1–3 times) had been
performed in seven of the 12 patients (58%) before stent placement. Of these
seven patients, five had the stented segment in the same location as that of
the lesion that had been dilatated 2–30 days prior. The other two
patients had prior intervention of the same access at 16 and 18 months before,
respectively.
All the vascular accesses routinely were first evaluated by high-resolution
(7–10 MHz) color sonography before our percutaneous interventions to
determine the stenotic site or the length of occlusion segment. Before the
procedure, 2,000 IU heparin were administered IV. Conscious sedation was
achieved using fentanyl citrate (Sublimaze, Abbott Laboratories) and midazolam
hydrochloride (Versed, Roche Pharmaceuticals). Prophylactic IV antibiotics
(cefazolin, 1g) were routinely given to patients with thrombosed accesses 30
min before the procedure. Under sonographic guidance and using the
conventional retrograde approach, the outflow veins were punctured at least 20
cm away from the anastomosis (for easy hemostasis after finishing the
procedure). To facilitate the guidewire recanalization through the thrombosed
outflow veins into arterial inflow, additional antegrade puncture of the
distal thrombosed drainage veins
[5] was used in two patients.
Direct balloon dilatations of the dysfunctional accesses were performed in
three stenotic lesions and four of the nine thrombosed accesses. Patients with
thrombosed large aneurismal dilatations (three patients) or long segmental
thrombosed outflow veins (> 15 cm in length in two patients) were initially
managed by infusion of urokinase (60,000–120,000 IU per hr) via direct
intrathrombus puncture by a 20- to 22-gauge vascular sheath for 3–4 hr.
Afterward, balloon angioplasty of vascular lesions was performed.
The selection of balloon size was determined according to the lesion site
and maturity of the lesion, that is, balloon catheters 6 mm and 8 mm in
diameter (Opti-Plats, Bard, inflated to 8–15 atm) were used for the
forearm and upper-arm lesions, respectively. However, a 5-mm balloon catheter
was chosen only if it had to cross the anastomosis into the radial artery or
to dilate the obliterated segment in an immature access. For brachiocephalic
(basilic) fistulas, if the brachial artery was included for dilatation, a 6-mm
catheter was used for the anastomotic stenosis. Resistant stenosis was dilated
with a 6–10 x 40 mm high-pressure balloon catheter (BlueMax;
Meditech, Boston Scientific) inflated approximately up to 25–28 atm.
Recoil venous stenosis was further dilated with a larger balloon catheter
(
2 mm in diameter) for 1–2 min. After the balloon dilatations,
residual adherent thrombus in the outflow veins, which had compromised the
access flow, was cleared by urokinase infusion for another 2–4 hr with
the same dosage mentioned above. We tried to avoid exceeding an infusion dose
of greater than 1 million IU during any one interventional procedure. The
residual adherent thrombus was further managed by forceful to-and-fro
compression directly on the thrombus by the sonography probe under real-time
image guiding. The patients were monitored in our observation room during the
thrombolytic period. The complication of venous rupture initially was managed
by low-pressure, prolonged inflation of the balloon catheter lasting several
minutes. Metallic stent was used only in selected patients who failed to
respond to prolonged balloon inflation.
In this study, the indications for metallic stent placement in the
peripheral outflow veins included recoil stenosis with residual stenosis
greater than 50% (two patients) or residual stenosis less than 50%, but with
early restenosis (attributed to the identical lesion) at less than 3 months
(four patients). Four patients' lesions were in the forearm veins; two
patients' lesions were in the upper-arm veins. Three of the six recoil lesions
were very close to the site of the arteriovenous anastomosis (AVA). One
patient underwent venous dissection to ensure access patency (Fig.
1A,
1B,
1C,
1D,
1E,
1F) and two patients
experienced venous rupture (in one of these patients, the access had been in
place fewer than 2 months [Fig.
2A,
2B,
2C,
2D,
2E]); all three lesions were
located in the forearm veins. Three patients had large thrombosed aneurysms (a
total of five aneurysms, three in the forearm and two in the upper arm). In
one of these patients, chronic organized thrombus in the upper arm was
resistant to 4-hr urokinase infusion and balloon fragmentation. The other two
patients had two thrombosed aneurysms. Because of clinical considerations (one
patient had terminal urinary bladder malignancy, the other experienced
vascular access occlusion for more than 72 hr), after successfully clearing
the thrombus for the lower aneurysm, the second thrombosed aneurysm (one in
the upper arm, and the other in forearm) was managed by deploying a metallic
stent (Fig. 3A,
3B,
3C). The sizes of the stents
were chosen to adapt to the diameter of the blood vessel, usually 1–2 mm
larger than that of the balloon used for the recoil or ruptured venous
lesions. However, for the thrombosed aneurismal lesions, stents 2 mm in
diameter or larger than that of the normal veins central to the aneurysm were
chosen. Two types of stents (Wallstent, Boston Scientific; Jostent, Jomed,
Abbott Laboratories) were used in this study, based on the size that was
available in our department. Stents 6–10 mm in diameter were placed in
eight forearm veins, and 8–10 mm in diameter in four upper-arm lesions.
No patients were placed on anticoagulants after the procedure. Informed
consent was obtained from each patient. This study was approved by the ethics
committee of our hospital.
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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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Follow-up was clinical for patients whose accesses functioned normally.
Only patients with occlusion of the vascular shunt, inadequate arterial inflow
(< 200 mL/min), or elevated venous pressure (> 150 mm Hg) underwent
repeated angiography. Primary patency was defined as the period from stent
deployment until any intervention of the access. Secondary patency was defined
as the length of time from stent placement until the access site was lost,
irrespective of the number of interventions. Accesses were assumed patent when
they remained functioning during hemodialysis. Patients with a patent access
were considered as lost to follow-up in cases of death. Kaplan-Meier analysis
was used to calculate the shunt patency rates.
Results
Eleven patients (92%) underwent successful dialysis after stent placement.
One patient with incorrect positioning of the stent failed to dialyze
adequately (arterial inflow 150 mL/min) immediately after the procedure. He
had surgical re-creation of a vascular shunt 1 week later. Twelve stents were
used (eight in the forearm, four in the upper arm), including four Wallstents
(Boston Scientific) and eight Jostents (Jomed, Abbott Laboratories). At the
time of data analysis (November 2003), seven patients continued to have patent
vascular accesses (follow-up period, 6–42 months). Three patients died
of unrelated causes with still-functioning accesses at 1, 1.5, and 4 months,
respectively. The other patient underwent surgical shunt re-creation 4 months
after the procedure.
Seven of the nine thrombosed-A-V fistula patients received urokinase
thrombolysis during the procedures. Of these, five patients underwent
thrombolytic therapy before balloon dilatation, and two patients immediately
after balloon dilatation. The dosages of urokinase infused in the three
patients with thrombosed aneurysms were 480,000, 720,000, and 960,000 IU,
respectively. The other four patients received a dose of urokinase ranging
from 180,000 IU to 480,000 IU. No complications of thrombolytic therapy in the
seven patients were encountered.
For the three patients with recoil lesions very close to the AVA, two
stents (one Wallstent [Boston Scientific] and one nitinol stent) were not
positioned appropriately in the outflow veins. The stents compromised the
blood flow at the anastomotic site, which resulted in immediate access loss in
one patient, and paradoxical blood supply in another patient (Fig.
4A,
4B,
4C,
4D). For the third patient, a
Wallstent was deployed in a U-shaped configuration into the supplying radial
artery (Fig. 4E,
4F). Her vascular access
continued to function for 22 months (secondary), until the 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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Two patients experienced vascular rupture after the balloon dilatations,
necessitating placement of a metallic stent. One of the patients had an
immature access (< 2 months) with a long-segment, obliterated outflow vein
at the middle third of forearm region. A rupture of the obliterated outflow
vein after dilatation with a 5-mm balloon catheter was noted. The access was
successfully salvaged by a stent placement and was functional for 12 months
(secondary patency). Access in another patient, who experienced vascular
rupture in the forearm vein, was salvaged for 4 months after stent placement.
In the patient with venous dissection, a short nitinol Jostent (8 x 26
mm, Jomed, Abbott Laboratories) was deployed 5 days after the initial balloon
dilatation due to flow compromise by the intima flap in the subsequent
dialysis. Patency in this access was maintained for 13 months (primary), until
the end of the study.
The primary patency (± standard error) of the 12 vascular accesses
at 3, 6, 12, and 24 months was 92% ± 8%, 81% ± 12%, 31% ±
17%, and 31% ± 17%, respectively. The secondary patency of the vascular
access was 92% ± 8% at 3 months and 81% ± 12% at 6, 12, and 24
months, respectively (Fig.
5).
Discussion
The role of metallic stent placement in the peripheral outflow veins in
hemodialysis patients may be controversial. To date, most of the articles
concerning the clinical application of metallic stent in hemodialysis patients
reported the treatment of central venous lesions or peripheral lesions in
graft patients. Only a few articles described the metallic stent placement in
native A-V fistulas and in only a small number of patients. Petar et al.
[12] and Antonucci et al.
[13] reported five and three
A-V fistula dialysis patients, respectively, with residual significant
stenosis after balloon dilatation in peripheral outflow lesions. Farber et al.
[14] treated peripheral venous
lesions with a Dacron (DuPont)-covered stent in five A-V fistula dialysis
patients. The patient population was small, and the indication for stent
placement was unclear. Vorwerk et al.
[15] performed stent placement
in 65 dialysis patients with 11 A-V fistula peripheral venous lesions. The
indications and overall stent and access patency rates were reported with
graft and A-V fistula patients together at different locations (forearm vein,
upper-arm vein, and central veins) in their series. Turmel-Rodrigues et al.
[17] reported on 47 dialysis
patients who underwent stent placement in a 7-year period. Of these 47
patients, 15 had native A-V fistulas. The indications of stent placement in
their study were greater than 30% residual stenosis (five patients),
percutaneous transluminal angioplasty–induced rupture (one patient), and
recurring stenosis (< 6 months) in nine patients. In our series, we used
stricter criteria in placing stents in patients with residual stenosis greater
than 50%, or with residual stenosis less than 50% but with inadequate inflow
during later dialysis or early failure of the access (< 3 months).
Turmel-Rodrigues et al. [17]
suggested surgical repair for lesions located less than 10 cm from the AVA
after unsatisfactory balloon dilatation. In our series, six lesions were at
this location, and three of them were very close to the AVA. Regardless of
which stent is chosen, we recommend stenting from inflow artery across the
anastomosis to avoid imprecise deployment of the stent, which might compromise
the arterial inflow.
Vorwerk et al. [15]
described seven patients who were stented due to venous dissection after
percutaneous transluminal angioplasty. We are not sure if these lesions really
were venous dissection. To our knowledge, no definite dissecting images in
dialysis vascular access were shown in previous articles. In our experience,
dissecting venous intima flap causing flow compromise is a very rare
complication. Theoretically, an intima flap in a retrograde fashion might have
chance to be compressed back toward the venous wall after restoration of the
antegrade arterial inflow. That is why we did not use a metallic stent
immediately when the intimal flap was found. Unfortunately, insufficient
inflow was still encountered during later hemodialysis.
Venous rupture is one of the most frequent and significant complications of
percutaneous transluminal angioplasty of vascular access, with an incidence
greater than or equal to 20%
[18]. Moderate or severe
rupture may not close after repeated prolonged inflation and could jeopardize
the patency of the access. In most of the reports that describe venous
rupture, the leakage occurred most frequently at the venous anastomosis of a
graft access
[8–9,
16]. Raynaud et al.
[16] reported 1.7% of severe
ruptures necessitating stent placement in their study. They treated 37
patients with venous ruptures with Wallstent (Boston Scientific), including 22
graft and 15 A-V fistula patients. The 6-month secondary patency in their
study was 89%, which was close to that of the study by Vorwerk et al.
[15] (88%) of venous stents
placed for other indications. Turmel-Rodrigues et al.
[19] reported technical
failure of percutaneous transluminal angioplasty in two immature native A-V
fistulas of less than 3 months' patency due to rupture after 5-mm balloon
dilatation. These authors initially considered immature access as a
contraindication for percutaneous transluminal angioplasty. We experienced the
same complication (rupture) after dilatation of the obliterated outflow vein
in an immature fistula. That access was successfully salvaged by deployment of
a metallic stent. Thus, in our daily practice, we do not consider the duration
of the access as a limitation for percutaneous transluminal angioplasty
procedure.
Several investigators have reported on various techniques to clear the
adherent thrombus in aneurismal dilated outflow veins in A-V fistula patients
[19–21].
Although all the authors stated that the adherent thrombus in the aneurysms
was cleared successfully based on follow-up venograms, no direct
high-resolution sonographic images confirm their statements. We agree that
fresh thrombus can be cleared by catheter aspiration or balloon fragmentation.
However, chronic organized adherent thrombus is seldom removed simply by
catheter aspiration. In our daily practice, we do not attempt to clear all the
adherent thromboses if brisk flow can be restored. However, it is not unusual
to find a residual large thrombus within the aneurysm after conventional
percutaneous transluminal angioplasty procedure, which would compromise
adequate blood flow. Vorwerk et al.
[15] used metallic stents in
five patients with chronic venous occlusion A-V fistula accesses in upper-arm
veins without a large amount of thrombus, and in two patients with aneurysms
in forearm veins. In their patients, the aneurysms were further managed by
surgical resection after stent placement for other stenotic lesions. For such
patients, we performed thrombolysis by direct injection of urokinase into the
ardent thrombus that compromised the flow volume. The access usually can be
restored successfully with a urokinase dosage ranging from
600,000–960,000 IU. However, for patients with a second thrombosed
aneurysm, a double dose of urokinase may risk potential prolonged coagulation
time. We agree with Schmitz-Rode et al.
[21] that excluding the
thrombus in the aneurysm by bridging it with a stent appears to be an
acceptable percutaneous alternative. Thus, we used metallic stent placement in
selective patients with, so far, satisfactory short- to mid-term results.
Placement of a metallic stent in the puncture site of a hemodialysis access
is debatable, and should be avoided if possible. However, in some patients,
stent placement at this site appears inevitable if the access is to be
salvaged by percutaneous intervention. A previous animal study in native
vessels showed the feasibility of direct puncture into the stent for
hemodialysis without short-term complications
[22]. Zaleski et al.
[10] and Turmel-Rodrigues et
al. [17] also confirmed the
feasibility of stent puncture in both PTFE graft and native A-V fistula
outflow veins. Thus, in our opinion, stent placement should not be limited
simply because the lesion site is close to the anastomosis in an A-V fistula
access.
Randomized, prospective studies comparing stents and angioplasty in
dialysis patients with graft vein stenosis suggest that there is no benefit
provided by routine stent deployment
[23,
24]. Thus, stents should be
used to treat only complications from or limitations of regular dilatation
[17]. Published primary and
secondary patency rates in peripheral dialysis graft access after stent
placement ranged from 10–31% and 50–100% at 1 year, respectively
[7–11,
23,
24]. Raynaud et al.
[16] reported primary and
secondary patency rates in 15 access rupture A-V fistula patients to be 48%
and 86% at 1 year, respectively. Turmel-Rodriques et al.
[17] reported 20% and 79%,
respectively in 15 A-V fistula patients with different indications in the same
study. In our study, the primary and secondary patency rates at 1 year were
31% and 81%, respectively, which were comparable to those in either graft or
A-V fistula patients.
In conclusion, our study confirms the value of metallic stent placement in
selective patients who fail to respond to conventional balloon dilatation. The
technical success and access patency rates after stent placement in dialysis
patients are considered satisfactory.
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Abstract
Introduction
