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38 Endovascular Techniques toManage Vascular Access Failure

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Fig. 38.3 Resolution of stenosis with use of a stent graft

tion of the stenosis and the patient’s clinical complaints (Fig.38.3). The stent graft should typically be at least 1 or 2mm larger than the normal graft or stula and should be extended into an outow vein that is at least as large as the stent graft.

Accessory Vein Obliteration

Accessory veins can prevent AVF maturation by diverting blood ow away from the main stula, leading to lower ows, smaller vessel diameters, and ultimately causing difculty with cannulation or obtaining adequate ows on dialysis. The pressure gradient established after creation of an AVF will lead to increased blood ow through the vein. Higher blood ow leads to more shear stress on the vessel wall leading to vessel dilation and AVF maturation; so any alteration in blood ow through the AVF can lead to a failure of maturation [7]. Although accessory veins can signicantly impact the maturation of AVFs, there are no clear guidelines on which accessory veins need to be ligated or obliterated. Traditionally, accessory veins with a diameter of one third or more of the AVF need to be obliterated; however, there are no studies that validate this arbitrary number [7]. One study tried to determine the criteria for accessory vein obliteration (AVO) by conducting computational uid dynamics and

established the following measures: (1) 60% or greater diameter of the main AVF, (2) 50% diameter of the AVF with at least one more accessory vein greater than 40% in diameter, (3) 50% in diameter and divides into branches of same size, (4) accessory vein likely to interfere with cannulation on physical examination, and (5) greater than 30% in diameter and associated with stenosis at site of origin [39]. However, these criteria were not clinically tested and veried and the guidelines for managing accessory veins are still evolving. This lack of selection criteria may explain the results of some studies that have not shown any benet in performing AVO [40, 41]. One of these studies was a meta-analysis looking at patients with immature AVFs undergoing either PTA alone or PTA with AVO, and there was no benet for PTA with AVO over PTA alone [40]. It is important to note that there was no specic selection process in determining which patient were to receive AVO. Regardless of these ndings, certain patients with an AVF that has failed to mature may still benet from AVO. This can be performed surgically with ligation of the accessory vein, or endovascularly with coil embolization [7] (Figs.38.4 and 38.5). When comparing open ligation to coil embolization, there was no signicant difference in the two techniques, with 64% maturation in the open group and 61% maturation in the endovascular group (p=0.84) [42]. Further studies are needed to assess the efcacy of AVO.

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Fig. 38.4 73year old male with a left radiocephalic AVF presents with difculty with cannulation and low ows even when cannulation is achieved. The patient was brought to the angiography suite for evalua-

Fig. 38.5 The competing outow vein was cannulated separately in order to minimize trauma to the intended cannulation segment of the AVF, and the competing outow vein was embolized using two coils with complete cessation of ow

tion, where stulogram through a microcatheter demonstrated dual outow in the forearm

Aneurysms andPseudoaneurysms

Although uncommon, aneurysm and pseudoaneurysm of AVFs are known complications that cause serious morbidity. In their systematic review, Al-Jaishi etal. reported an aneurysm incidence of 0.04 per 1000 patient days [43]. Aneurysmal dilation of the AVF has been linked to repeated

cannulation of the stula, with one study nding that alternating puncture sites protects against the formation of pseudoaneurysms [44]. Pseudoaneurysms are perivascular collections of blood that are in direct continuity with the AVF lumen and have been also linked to AVF vessel injuries caused by cannulation [45]. Aneurysms and pseudoaneurysms can both cause overlying skin thinning and ulcer for-

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mation, as well as limit the availability of cannulation sites and, if left untreated, can lead to exsanguination [43, 45]. While the size of an aneurysm/pseudoaneurysm is not an indication for treatment, the KDOQI recommends evaluation for new and follow-up on existing aneurysms at each dialysis session, with use of duplex if needed for evaluation of size, size progression, presence of stenosis, and impact on dialysis via the AVF [2]. It is recommended to avoid cannulation through the dilated segment to avoid further trauma to the vessel wall and potential vascular access hemorrhage [2, 46]. The KDOQI and Canadian Society of Nephrology hemodialysis guidelines recommend intervention when the skin overlying the AVF has been compromised (erosion or ulceration), there is a risk of life-threatening hemorrhage, or cannulation sites have become limited [2, 47]. Endovascular management is similar to that of aneurysms found in other vascular beds and includes exclusion of the aneurysm or pseudoaneurysm by inserting a stent graft. Available studies demonstrate primary patency rates of 100% at 30 days,

72.7% at 3 months, and 36.4% at 6 months [48, 49]. One study showed a non- signicant higher risk of infection (odds ratio 5.0, 95% condence interval [0.38, 66.01]) with stent graft insertion in patients with skin erosion over the pseudoaneurysm [49]. Other authors reported a 28.9% complication rate including migration, fracture, erosion, or rupture after stent graft insertion [50]. Further studies are needed to evaluate the role of stent grafts in the treatment of vascular access circuit aneurysms and pseudoaneurysms.

Central Venous Stenosis

Stenosis of the central veins (including the subclavian vein, innominate veins, and superior vena cava) can result in signicant morbidity for hemodialysis patients with AVFs and AVGs. Many patients may have asymptomatic stenosis which may be incidentally discovered during venography; as such, the true incidence of central venous stenosis (CVS) varies widely with reported values ranging from 3 to 60% among ESKD patients on HD [51–55]. Symptomatic stenosis can present with multiple issues, including difculty with cannulation, prolonged bleeding following needle removal, or decrease in clearance [56]. Other ndings suggestive of CVS include ipsilateral extremity edema, pain, or development of prominent venous varicosities or collaterals [56, 57]. Risk factors associated with the development of CVS include current or prior presence of central venous catheters, DVT, and cardiac rhythm devices such as pacemakers [2, 58].

Percutaneous Transluminal Angioplasty

Endovascular techniques are the current mainstay of CVS treatment, with the KDOQI recommending PTA only for moderate to severe symptoms or when efcacy or clearance is compromised [2] (Figs.38.6 and 38.7). The initial technical success rates of PTA are high, ranging from 70% to 90% [59]. However,

Fig. 38.6 Left subclavian vein stenosis leading to left arm swelling after left brachial artery to axillary vein AVG placement

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Fig. 38.7 Treatment with balloon angioplasty leads to signicant luminal gain and improvement in left arm swelling

D. B. Semaan et al.

due to venous elastic recoil, restenosis is common and patency rates at 12months are quite poor, ranging from 12 to 50% [59].

Management of restenosis following PTA may include repeated balloon angioplasty or possibly stent placement. With repeated PTA, secondary patency rates have been reported as high as 60% at 12months, though close monitoring and repeated intervention are often required [60]. If signicant residual stenosis persists after repeated PTA, the KDOQI guidelines endorse the use of intraluminal stenting [2], which will be discussed below.

Stenting oftheCentral Venous System

As noted above, current guidelines support the use of stenting for CVS only after multiple unsuccessful rounds of PTA [2]. Despite high technical success rates, initial studies employing bare metal stents showed 12-month primary patency rates of 19–21% [61–63]. When comparing longterm patency of PTA versus PTAS, bare-metal stents have not demonstrated superior outcomes [61, 64]. Bare-metal stents are additionally associated with migration, shortening, and fracture and thus are not recommended for use in the region of the thoracic outlet due to risk of external compres-

sion [2, 3, 65]. A retrospective analysis investigating the use of self-expanding bare metal stents in central and peripheral veins reported a 12-month patency rate of 67% with a mean patency duration of 14.9months [66]. In a 2007 study, PTAS was performed in 26 patients with bare metal stents and primary PTA alone was performed in 47 patients. Primary patency was equivalent between groups with 76% patency for both groups at 30-day and 12-month rates of 29% for PTA and 21% for PTAS (p=0.48) [61]. The authors concluded that both PTA and PTAS are safe options which both often require additional interventions.

More recently, stent grafts have emerged as a promising option for endovascular treatment of CVS.In several recent retrospective analyses comparing PTA, bare-metal stents, and stent grafts, stent grafts consistently demonstrated superior long-term patency. Reported 12-month patency ranged from 45.1 to 58%, 75 to 78.6%, and 82.4 to 100% for PTA, bare-metal stents, and stent grafts, respectively [67, 68]. In both studies, primary patency for stent grafts were superior to both PTA and bare-metal stents. The advantage of stent grafts is thought to be related to their relatively inert and stable nature, providing a platform for endothelialization while creating a physical barrier that reduces intimal hyperplasia (Kundu 2010).

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Case Presentation

Continued from page 409

The patient was severely hyperkalemic, and a dialysis catheter was placed in order to temporize the patient and provide dialysis access prior to thrombectomy. Due to lack of available operating room time, a percutaneous approach was chosen. Tissue plasminogen activator (t-PA, Alteplase) 2mg, buffered in 3000units of heparin and 5mL of sterile water was injected into the thrombosed AVG through a 22

gauge Angiocatheter, after the fashion of “Lyse and wait” [20] (Figs.38.8 and 38.9). After several minutes, the AVG became pulsatile throughout its length.

When an appropriate angiography suite was available, the patient was brought for stulography, demonstrating a severe stenosis in the outow (Fig. 38.10), which responded to aggressive balloon angioplasty, including high pressure balloons up to 40 atmospheres (Fig.38.11). The patient did well and was discharged home with a functional AVG.

Fig. 38.8 Components of the “Lyse and wait” technique include Alteplase (2mg) and heparin (3000units) [20]

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Fig. 38.9 A 22 gauge angiocatheter directed to the venous anastomosis is used to administer the medications

Fig. 38.10 Initial stulography after lysis demonstrated a severe stenosis in the venous outow and residual thrombus

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Fig. 38.11 Completion stulogram after aggressive plain and high pressure balloon angioplasty exhibits an excellent radiologic result

Table 38.1 Endovascular toolkit for the endovascular management of failing arteriovenous access. These are only a few suggested options based

on the author’s experience

Manufacturer Size/length

Guidewires

Any standard-access wire

Hydrophilic-coated wire Glidewire (Terumo)

ZIPwire (Boston Scientic) SplashWire (Merit Medical)

Sheaths

Any standard-access sheath, sizing dependent on requirements for balloon or stent delivery. Short sheaths can be useful for access, while longer sheaths may be needed for support when crossing difcult lesions.

Coils

Nestor coils Cook Medical

Stent grafts

Viabahn WL Gore 7–10mm/ length as required to cover the lesion Flair BD 7–10mm/ length as required to cover the lesion Covera BD 7–10mm/ length as required to cover the lesion Thrombectomy devices Fogarty thru-lumen embolectomy catheter Edwards Lifesciences 4 Fr (9mm inated)

Cleaner XT rotational thrombectomy system Argon Medical Devices 6 Fr/ 65cm AngioJet thrombectomy system AVX Boston Scientic 6 Fr/ 50cm Indigo aspiration system/ CAT mechanical thrombectomy catheter

Multiple 6–9 Fr/6–10cm

Penumbra CATD: 8F (2.67mm, 50cm length)

0.035″

6 Fr/25+ cm

0.035″ 4, 6, 8mm

5.5 Fr (11mm inated)

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Conclusion

Endovascular treatment options of vascular access failures offer a minimally invasive treatment option for ESKD patients on hemodialysis with malfunctioning and failed

AV access. A well-stocked endovascular toolkit (Table 38.1) is invaluable. When performed by experi- enced and well-trained clinicians, percutaneous options can provide immediate and successful treatment of failing dialysis access.

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Part VII

https://t.me/medicina_free

Coronary Artery Disease

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